Archived: Trevern Residential and Nursing Home

Trevern is a 'care home' with nursing that provides accommodation for a maximum of 40 adults, of all ages with a range of health care needs and physical disabilities. At the time of our inspection there were 38 people living at Trevern. The service is situated in the town of Falmouth. The building is divided into three areas known as The Wing, The Flats and The House. Each area has its own lounge and dining area. People's bedrooms were personalised and were for single occupancy. There were a range of aids and adaptations in place including bathing facilities designed to meet the needs of the people using the service.

People’s experience of using this service and what we found

The service had changed the way staff rosters were calculated. Staff told us rosters were now consistent and they had a clearer work pattern. Additional recruitment had improved staffing levels with less reliance on agency staff. However, agency staff continued to fill gaps as they occurred.

There was a good skill mix on each shift. The service had increased the level of nurses on day shift. Where possible two nurses were on duty. This meant there was more flexibility in service delivery.

Staff were recruited safely. Staff told us they felt supported in their role. There had been gaps in supervision during the COVID-19 pandemic, but all staff had received a recent appraisal and there was a plan in place for regular one to one support. Senior managers provided on call support for out of hours and weekend cover.

Cleaning and infection control procedures had been updated in line with COVID-19 guidance to help protect people, visitors and staff from the risk of infection. Government guidance about COVID testing for people, staff and visitors was being followed.

Visiting arrangements for people’s families had been facilitated, in line with government guidance at any given time, throughout the pandemic. Nominated relatives were able to make visits to see their loved ones, and this had been welcomed.

People received their medicines safely as prescribed for them. Regular audits identified where errors had occurred. Action was taken in these instances to learn from these errors through additional training and support.

Electronic care planning provided staff with guidance to ensure people’s needs were met. Risks were identified and staff had clear instructions to help them support people to reduce the risk of avoidable harm.

Feedback from people and their relatives about the service’s performance was valued by the registered manger and any issues raised were investigated and action taken where necessary. The duty of candour was understood by the registered manager and relatives told us the service communicated with them effectively.

Rating at last inspection

The last rating for this service was Good (published 13 February 2020).

Why we inspected

We received concerns in relation to management of the service, staffing, the quality of care people received and limited staff support. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The provider had taken steps to mitigate risk by making changes to how the service was being staffed. Recruitment had increased and staff told us management support had improved.

A review of governance systems was continuing, and changes were being made where necessary to ensure they were effective.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Trevern on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Trevern is situated in the town of Falmouth. The building is split into three units known as The Wing, The Flats and The House. Each unit has its own lounge and dining area. People's bedrooms were personalised and were for single occupancy. Each unit has a range of aids and adaptations in place including bathing facilities, designed to meet the needs of the people using the service.

People’s experience of using this service and what we found

At the previous inspection in November 2018 there were concerns around staffing levels, a high reliance on agency staff and there was no registered manager in post. We found at his inspection that there had been changes in the management team personnel, recruitment of care and nursing staff and that the reliance on agency staff had reduced significantly. In addition, staffing levels in the service had increased. People, relatives and health and social care professionals were all positive about the changes in staffing and that there was now a permanent management team and regular staff team in post. In addition, they reported that with the increase in staffing they felt their needs were met promptly.

Staff were recruited safely in sufficient numbers to ensure people’s needs were met.

Staff were positive about the changes in the service and felt that staff morale had risen.

Some people were not able to tell us verbally about their experience of living at Trevern. Therefore, we observed the interactions between people and the staff supporting them.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Any controlled practices were regularly reviewed to ensure they remained the least restrictive option and were proportionate and necessary.

There were systems and processes in place to monitor the Mental Capacity Act, and associated Deprivation of Liberty Safeguards assessments and records.

The service supported people to manage some aspects of their finances. The company’s policy and procedure did not adhere to the principles of person-centred care. We have made a recommendation about this in the Safe section of this report.

Staff were highly committed to ensuring people lived fulfilling lives and were protected from social isolation. The focus of people's care was individualised and focused on promoting people's independence as well as their physical and mental well-being.

People received an extensive range of meaningful activities which focused on the persons individual interests and abilities.

People enjoyed the meals and their dietary needs had been catered for. This information was detailed in people's care plans. Staff followed guidance provided to manage people's nutrition and pressure care.

People received care and support that was individual to their needs and wishes. Care plans were regularly reviewed and updated and were an accurate reflection of people’s needs and wishes.

People were supported by staff who had received training to ensure their needs could be met. Staff received regular supervision to support their role.

People had good health care support from professionals. When people were unwell, staff had raised the concern and acted with health professionals to address their health care needs. The staff worked in partnership with health and care professionals.

Staff were patient and friendly, and people's privacy and dignity were respected. Staff knew how people preferred their care and support to be provided.

Risk assessments provided staff with sufficient guidance and direction to provide person-centred care and support.

Audits were carried out regularly to monitor the service provided. Actions from these audits were being acted upon to further improve the service.

Effective governance systems were in place, ensuring people received consistent care.

Rating at last inspection

At the last inspection the service was rated as requires improvement (report published 25 January 2019) and we imposed a condition on the providers registration of the service which required the service to report to CQC each month on areas of concern identified at that inspection. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the conditions applied after the previous inspection of 25 January 2019 were met.

Why we inspected: This inspection was carried out to ensure improvements required at the last inspection had been made.

Follow up: We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Trevern is situated in the town of Falmouth. The building is split into three units known as the Wing, The Flats and The House. Each Wing has its own lounge and dining area. People’s bedrooms were personalised and were for single occupancy. Each wing has a range of aids and adaptations in place including bathing facilities, designed to meet the needs of the people using the service. There were people living at the service who were living with dementia and were independently mobile. There was pictorial signage at the service to support some people, who may require additional support with recognising their surroundings. There was a courtyard which people could use.

The last comprehensive inspection took place in November 2017. As the service had breaches of regulation we undertook a focused inspection in January 2018 to review the actions the provider had taken to address the concerns identified. The service was rated as Requires Improvement at that time. There were concerns around staffing levels, a high reliance on agency staff and audits had not been completed to identify where there were shortcomings in the service. We imposed conditions on the providers registration to send us regular updates as to how these issues were to be addressed.

This unannounced comprehensive inspection took place on 29 November 2018. At the last inspection, in January 2018 the service was rated Requires Improvement. At this inspection we found the service remained Requires Improvement.

There was no registered manager in post. Since the last inspection there had been three interim managers in post. The interim manager at this inspection was appointed in October 2018 and was contracted to work until the end of January 2019. The provider had been actively recruiting to this post but no candidate had been appointed.

People told us that they were aware that there had been a number of manager changes at Trevern and were not able to identify who the current manager was. Health and social care professionals were also concerned about the number of management changes. They told us they were not sure who to speak to when they phoned or visited the service as staffing personnel changed. Staff told us that they were “disillusioned” in respect of the lack of constant leadership in the home.

There had also been recent changes to the Cornwall Care Senior management team with a new appointment to the Chief Executive Officer (CEO) and interim operations director. Staff were still uncertain regarding how this change would affect the organisation, but were pleased to have received a newsletter from the CEO introducing herself to the staff.

Staff confirmed that supervision had not occurred regularly. With the appointment of the interim manager and clinical deputy manager this was now being addressed. Staff meetings had also not occurred regularly. This did not give staff the opportunity to voice their opinions or concerns regarding any operational changes to the service.

People were positive about the care they received from staff at the service. However, they told us that there remained a reliance on agency staff. People told us that they were hesitant to call for assistance as they were aware that staff were ‘busy’ or ‘short staffed’. We received a mixed response from people in how quickly call bells were answered. Comments included “I can generally get help when I need it but I know the staff are really busy. Sometimes I say I would like to get up but they have other people to look after and say I’ll just have to wait. I don’t mind that because other people need them too.”

Staff were also concerned about how the service was staffed and how staff were deployed to be able to meet people’s needs in a timely manner. Staff rotas showed that the minimum levels of staffing to meet people’s current care needs were being met. However there continued to be a reliance on agency staff to make this possible. It is acknowledged that the provider had attempted to address staffing levels and some improvements had been made, such as block booking to provide more consistency for people, and the ongoing recruitment campaign. However, this inspection identified that there remain concerns from people and staff in how staff were deployed to meet their needs. We have made a recommendation in this respect.

On the day of the inspection we observed staff interacted with people in a caring and compassionate manner. People told us they were happy with the care they received and believed it was a safe environment. We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and understood their needs and preferences. The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes.

Care plans were being reviewed. This was to ensure they gave direction and guidance for staff to follow to help ensure people received their care and support in the way they wanted. Staff were aware of each individual’s care plan, and staff told us care plans were informative and gave them the individual guidance they needed to care for people. Risks in relation to people’s care and support were assessed and planned for to minimise the risk of harm.

Accidents and incidents that took place in the service were recorded by staff in people’s records. Such events were audited by the manager. This meant that any patterns or trends would be recognised, addressed and the risk of re-occurrence was reduced.

Staff held a daily handover where information about people’s care would be shared, and consistency of care practice could then be maintained. This meant that there were clearly defined expectations for staff to complete during each shift.

There were systems in place for the management and administration of medicines. People had received their medicine as prescribed. Regular medicines audits were being carried out on specific areas of medicines administration.

The clinical deputy manager was currently reviewing all people at the service to ensure that their rights were protected in line we with the Mental Capacity Act 2005 and that the Deprivation of Liberty Safeguards (DoLS) were understood and applied correctly.

People were protected from abuse and harm because staff understood their safeguarding responsibilities and were able to assess and mitigate any individual risk to a person’s safety. Other training identified as necessary for the service was provided and updated regularly

People had access to activities both within the service and outside. Activities co-ordinators organised a planned programme of events. Staff ensured people kept in touch with family and friends. Relatives told us they were always made welcome and could visit at any time.

There was a system in place for receiving and investigating complaints. People we spoke with had been given information on how to make a complaint and felt confident any concerns raised would be dealt with to their satisfaction.

Following our last inspection the provider wrote to us detailing the actions they planned to take to ensure they were meeting the requirements of the Regulations. We carried out this focused inspection to check they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Trevern on our website at www.cqc.org.uk.

Trevern is a ‘care home’ that provides nursing care for up to a maximum of 40 predominately older people. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were 34 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs. Trevern is part of the Cornwall Care group which has several nursing and residential homes in Cornwall.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a manager at the service who had been in post since early September 2017. They had recently completed the appropriate checks and were applying to CQC to be registered.

We found the service was highly dependent on agency and bank staff. Although as far as possible, staff who were familiar with the service were used, this was not always the case. Staff told us, even when the service was fully staffed there were not enough care assistants on shift to meet people’s needs in a timely manner. This was more difficult if some of the staff team were unfamiliar with the service and people’s needs. We identified a breach of the regulations.

We still had concerns in respect of the effectiveness of auditing systems. We found gaps in monitoring records used to record when people had received care. Although these records had been audited the gaps had not been noted or any action taken to look at why the records had not been completed. Audits to give an oversight of people’s weights had failed to identify when people were not being weighed as often as outlined in their care plan.

Behaviour records had not been completed correctly. This meant potentially relevant information to guide staff to support people in a way which meant they were less likely to become anxious and distressed was not being captured. We concluded the provider had failed to take adequate action to ensure the conditions of the warning notice were met.

Risks to people’s well-being and health were well documented. There was clear guidance for staff to follow to protect people from foreseeable harm. Staff communicated at handover and throughout the day to help ensure they were aware of any change in people’s needs.

Improvements to the environment had been made since our last inspection. Confidential information was kept securely. Keypads had been fitted to various doors throughout the building so potentially harmful products and equipment could be safely stored.

There were robust arrangements in place for the ordering, storing and administration of medicines.

Cornwall Care had a clear management structure in place. The manager told us they were well supported and had regular contact with the senior management team.

Within the service there was a well-defined hierarchy. The manager was supported by a deputy manager. There was also a senior nurse employed who had responsibility for overseeing the management of medicines.

There were plans in place to improve and develop the service. For example, the call bell system was due to be improved to make it easier for staff to quickly identify which bells had been activated and increase the volume of the bells.

The service was rated as Requires Improvement. This is the fourth consecutive time the service has been rated Requires Improvement. We identified breaches of the Regulations. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

At this comprehensive inspection we checked to see if the provider had made the improvements necessary to meet the breaches identified at the inspection in May 2017. We found improvements had been made in some of the areas of concern. Capacity assessments were up to date and the processes in place to ensure the service was acting in accordance with the legislation were robust. Progress had been made in terms of gathering personalised information about people’s backgrounds and life histories. We found the service was no longer in breach of Regulations 9 and 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We still had concerns in respect of the management of identified risks to people’s well-being, gaps in monitoring records and the stability of the management of the service. At our last inspection we had also had some concerns in respect of the environment. At this inspection we again found similar concerns. This is the third consecutive time the service has been rated Requires Improvement.

Trevern is a ‘care home’ that provides nursing care for up to a maximum of 40 predominately older people. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were 34 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs. Trevern is part of the Cornwall Care group which has several nursing and residential homes in Cornwall.

There was a registered manager for the service. However, they had not worked at Cornwall Care for some time. CQC had not received an application to cancel their registration at the time this report was issued. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a manager at the service who had been in post since early September 2017.

At our inspection in November 2016 we found a lack of guidance for staff on how to support people who had been identified as being at risk and we issued a recommendation. In May 2017 we again found examples in people's records where a risk had been identified and the care plan did not

contain guidance for staff on how to reduce the risk or meet the person's associated care needs. At this inspection we found staff did not have clear guidance in place on how to care for people who were at risk of developing pressure sores. Although it was recorded when people required repositioning to protect their skin integrity it was not stated how often this should happen. In addition we found that, where a risk had been identified and documented, action was not taken to protect the person in line with care plan.

At our inspections in November 2016 and May 2017 we found there was a lack of stable leadership at the service. At this inspection there was a new manager in the post. They told us they were in the early stages of applying for registration and were committed to the role and driving up standards. However, they had not been in the role long enough for us to make a judgement about their leadership of the service. It was too early for us to be confident that the management position at the service was stable.

At our inspections in November 2016 and May 2017 we identified gaps in records used to monitor people’s health. At this inspection we found some recording systems had improved. However, we continued to find inconsistently completed monitoring charts in relation to people’s skin condition. Audits had failed to identify these gaps or highlight other issues of concern found at the inspection.

We identified issues in relation to the safety of the environment. Keys to cupboards containing potentially hazardous substances were easily available. There were several concerns related to infection control. For example, we found a soiled bed pan in a shared toilet, waste bins in toilets were uncovered, there was no suitable clinical waste bin in one treatment room and cleaning schedules were not consistently in place.

Following our inspection the provider contacted us to tell us of immediate action they had taken in light of the concerns raised.

People told us they felt safe. Staff were knowledgeable about processes for reporting safeguarding concerns and believed these would be addressed. The induction process for new staff included information on equality and diversity and how to help ensure people’s rights were protected. Staff training was regularly updated to enable them to keep up to date with any changes in legislation or working practices. There were robust recruitment processes in place. All staff were supported by an on-going programme of supervision and annual appraisals.

There were safe arrangements in place for the storing and administration of people’s medicines. We identified a surplus of stock of some prescribed food supplements. The manager addressed this at the time of the inspection. Medicine Administration Records were appropriately completed. Arrangements for the storage and administration of medicines which require stricter controls by law were robust.

There were enough staff on duty to meet people’s needs. The service had been short staffed and dependant on the use of agency staff to ensure people were supported appropriately This had recently improved and the management team told us agency use had dropped considerably in recent months. Two new nurses had been recruited and interviews for care staff were scheduled for the following week. We saw staff stopping to spend time chatting to people and call bells were answered promptly apart from one occasion.

People told us the food was good and we saw choices were offered to meet people’s preferences. When people were identified as being at risk due to poor food and fluid intake they were closely monitored and supported to eat high calorie diets. Kitchen staff were aware of people’s dietary needs and preferences. They worked to create meals which were appetising for all while continuing to meet their health needs.

Staff were caring in their approach to people and demonstrated a good knowledge of people’s likes and dislikes and backgrounds. They showed compassion and patience when supporting people who were confused or taking time to complete a task. People’s privacy and dignity was respected.

There was an activity co-ordinator in post who helped arrange activities for groups and individuals. People were regularly supported to have trips into the local community. Where individuals had specific needs in relation to eating and drinking or mobility, arrangements were put in place to ensure these were met. This meant people were not excluded from activities because of their disability. External entertainers visited the service to provide additional entertainment.

Cornwall Care had plans in place to improve the environment at Trevern and the service provided. This included updating carpets and furnishing and making alterations to the arrangement of some rooms. Relatives were kept informed of any imminent changes. In addition there were plans to increase the use of technology to support more efficient care and treatment.

Staff morale was good and staff told us they felt involved in the running of the service and able to raise any concerns. A relative told us; “There have been huge steps made by the new management."

We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the end of the full version of the report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

At the previous comprehensive inspection on 21 November 2016 we found breaches in the legal requirements relating to staffing levels, management arrangements, monitoring records, and the security arrangements of the building. Following the inspection in November 2016 the provider sent the Care Quality Commission an action plan outlining how they would address the identified breaches. We undertook this inspection to check the provider had followed their plan and to confirm that they now met legal requirements.

Trevern is a care home that provides nursing care for up to a maximum of 40 predominately older people. At the time of the inspection there were 36 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs.

There was a registered manager at the service who had not been at work for several months. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a temporary manager in post who supported us throughout the inspection. The temporary manager will be referred to throughout this report as "the manager".

At the previous inspection, the service had identified the minimum numbers of staff required to meet people’s needs. We found these were not being consistently met. The management team had identified there were high levels of staff absenteeism due to last minute sickness and this was contributing to low staffing numbers. Action was being taken to address this issue and a new sickness management policy had been introduced. However, it was too early for us to evaluate the effectiveness of this new policy. At this inspection, we found improvements had been made. We reviewed the rotas held by the service and observed staffing levels. We found that staff were able to respond to people in an unhurried way and call bells were answered promptly. The manager told us the sickness policy worked well and numbers of absenteeism had reduced.

At the previous comprehensive inspection in November 2016, we found that care plans contained risk assessments for a range of circumstances. The assessments were updated regularly to reflect people’s changing needs. However, there was a lack of guidance in place for staff on how to care for someone who had been identified as at risk. We made a recommendation in the previous inspection report about the management of risk. At this inspection, we did not feel that this issue had been adequately addressed. We continued to find examples in people’s records were a risk had been identified and the care plan did not contain guidance for staff on how to reduce the risk or meet the person’s associated care needs.

At the previous inspection in November 2016, we found that people's health needs were monitored. However, records documenting this were inconsistently completed. There were gaps in records and some had not been dated. This meant it was difficult to establish whether people had received care according to their plan of care. This continued to be a concern at this inspection. We found frequent examples in people’s records where we could not gain an accurate picture of the care people were receiving.

At the previous comprehensive inspection, we found there was a lack of clear oversight of the service. Although some staff had been given responsibility for various areas, for example, rotas and auditing, this had not prevented the problems identified at this inspection from occurring. An interim manager was in place but they had not gained a good working knowledge of the service. Relatives were not clear as to the arrangements for managing the service and some told us communication had been poor. At this inspection, we found there was a manager in post. This manager was committed to raising standards at the service and addressing areas of concern, however they had not been in post for long enough for us to make a judgement about their leadership of the service. We continued to find that although audits had taken place, they had failed to identify issues found by us during the inspection.

We found issues relating to the administration and recording of covert medicines. Covert medicine is medicine given to a person without their knowledge, for example, being crushed in their food or drink. Staff told us, if there was a covert agreement in place, they would routinely administer the medicines covertly, rather than first offering the person the medicine overtly. This did not comply with their own policy on covert medicines which clearly stated that covert administration should be the last resort. We found an example where the medicines on the persons covert agreement did not correspond with the medicines listed on the person’s medicines administration record (MAR).

People’s rights were not always protected through the correct use of legal frameworks. For example, when required, people had been assessed under the Mental Capacity Act (MCA) by staff, however, the assessments we found were either completed in 2014 or had not been dated. It was therefore not possible to gain an accurate picture of their capacity to make decisions.. The manager had sought authorisations under the Deprivation of Liberty Safeguards (DoLS) when needed, however, where the restrictions in place in people’s care plans had changed, this had not always been reported to the Supervisory Body.

There was a lack of personalised information in many of the care records we reviewed. This meant staff might not be aware of people’s backgrounds, histories, preferences and routines. Most care records we reviewed contained a document called; “My life narrative”, but in most cases, this was left blank. Some staff we spoke with confirmed they did not feel they knew enough about the lives of the people they supported. People had access to activities, however these were basic and some people told us there was not enough to do. We have made a recommendation about this.

Some people we spoke with provided negative feedback on the food. We noted that some food offered on the first day of the inspection did not look appetising. We found that when people needed their food to be pureed, the food was not presented in an appetising way, for example, by using moulds to make the foods replicate it’s original form. The service did have the moulds needed to do this, but they were not being used. We inspected the kitchen and found limited information on people’s dietary needs for the cook. The cook relied on the care staff to plate the food up for individual people from the trolley, meaning there was a potential for errors.

We found some concerns with the environment. We noted the sluice room to be frequently unlocked and unattended. We found a broken window in one area of the home. We also found a quiet lounge with a heavily stained carpet, mismatched furniture and one armchair without armchair covers, with a fleece blanket over the top. We also found a key cabinet containing keys to different areas of the home, which was unlocked and open, with the keys on display.

People and their relatives told us the service was safe. People were supported by staff who understood how to recognise and report any signs of suspected abuse or mistreatment. Staff had been safely recruited, and had undergone checks to help ensure they were suitable to work with people who were vulnerable. People were supported by staff who had undergone training to help ensure they could meet their needs effectively. Staff were supported by a thorough induction process which including shadowing more experienced staff. All staff were supported by an ongoing programme of supervision as well as an annual appraisal.

People and their relatives told us the staff were kind. Staff spoke about the people they supported with fondness and affection. People’s dignity was protected by staff who were respectful and compassionate. The atmosphere at the service was pleasant and relaxed and people appeared comfortable and at ease. People’s confidential information was securely stored.

There were suitable numbers of nursing staff on duty to provide nursing care. If people became unwell, the service made prompt referrals to doctors or specialists. People had access to a range of health and social care professionals including social workers, chiropodists and speech and language therapists.

We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the end of the full version of the report.

We undertook this inspection to check the provider had followed their plan and to confirm that they now met legal requirements. We also looked at the areas that had been raised to us as concerns.

Trevern is a care home that provides nursing care for up to a maximum of 40 predominately older people. At the time of the inspection there were 36 people living at the service. Some of these people were living with dementia. The building is split into three units known as, The Wing, The Flats and The House. The Wing is used for people who have complex health needs.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Although there was a registered manager in post at the time of the inspection the service was being overseen by an interim manager.

The service had identified the minimum numbers of staff required to meet people’s needs, these were not being consistently met. The management team had identified there were high levels of staff absenteeism due to last minute sickness and this was contributing to low staffing numbers. Action was being taken to address this issue and a new sickness management policy had been introduced. However, it was too early for us to evaluate the effectiveness of this new policy.

Care plans contained risk assessments for a range of circumstances. The assessments were updated regularly to reflect people’s changing needs. There was a lack of guidance in place for staff on how to care for someone who had been identified as at risk.We have made a recommendation in the report about the management of risk.

Systems for the management and administration of medicines were robust. Medicines were stored safely and securely and regular audits were carried out.

Improvements had been made to the environment and more were planned. Some areas were in the process of being redecorated. Arrangements to minimise the effect of the redecorating on people’s daily lives were in now place although previous improvements had not been well planned.

People had access to activities. Two healthcare assistants had additional responsibilities as activity co-ordinators. They organised visits from outside entertainers as well as providing activities themselves. There were also regular trips out to local events and landmarks. People who stayed in their rooms had more limited access to activities.

People's health needs were monitored. However, records documenting this were inconsistently completed. There were gaps in records and some had not been dated. This meant it was difficult to establish whether people had received care according to their plan of care.

There was a lack of clear oversight of the service. Although some staff had been given responsibility for various areas, for example, rotas and auditing, this had not prevented the problems identified at this inspection from occurring. An interim manager was in place but they had not gained a good working knowledge of the service. Relatives were not clear as to the arrangements for managing the service and some told us communication had been poor.

The provider was implementing changes within the service and new systems had been introduced to achieve this. Changes had been made to the way in which staff were deployed throughout the service. Staff and relatives told us this was a positive move which helped ensure people received continuity of care. However, the new processes were not sufficiently embedded to allow us to make a judgement as to their effectiveness. We will check this at the next comprehensive inspection.

We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the end of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, observing interactions between staff and people, and from looking at records.

Is the service safe?

From the two outcomes we looked at during this inspection we found the service was not safe. The environment was in need of some attention. Internal windows were not clean. Items were stored inappropriately in corridors and bathrooms.

There was no effective process for assessing and monitoring the risks to people within the premises to identify issues that required attention within the home.

Staff were clear on the action they should take if they had any safeguarding concerns.

Is the service responsive?

From the two outcomes we looked at during the inspection the service was not responsive. People did not always experience care, treatment and support that met their needs. Care plans were not reviewed to reflect changes in people's needs.

People were not always provided with the correct incontinence product and communally used toiletries were found in all bathrooms.

There was very little meaningful activity for people

You can see our judgement on the front page of this report.

During our inspection, we found people's views and experiences were taken into account in the way the service was provided and delivered in relation to their care, for example, we heard people refuse offers from staff and saw staff respected this.

People experienced care, treatment and support that met their needs and protected their rights, and people were protected because there were sufficient skilled, and experienced staff on duty.

Complaints were recorded and dealt with in a sensitive manner. Records were stored securely, and were accurate and legible.

We used our SOFI (Short Observational Framework for Inspection) tool for approximately one hour in a lounge/dining area. The SOFI tool allowed us to spend time watching what was going on and helped us record how people spent their time, the type of support they got and whether they had positive experiences. We saw people's privacy and dignity was respected and staff were helpful. We did not see people engaged in activities, although we saw people chatted with each other and with staff.

During our inspection, we found people's privacy, dignity and independence were respected and people's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

People experienced care, treatment and support that met their needs and protected their rights, and people were protected against abuse and the risks associated with medicines, because the staff had had training and there were appropriate policies and procedures in place.

We found staff received appropriate professional development and supervision.