CQC report explained · a nursing home
What the CQC found at Tregenna House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks, medicines, staffing, infection control and emergency arrangements were managed safely, although some premises maintenance needed improvement.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- The home had clear leadership, effective quality checks and a positive culture. Managers worked well with relatives and health and social care professionals.
What inspectors found, March 2023
Tregenna House was rated Good; inspectors found people were safe and the home was well-led, but some maintenance needed attention.
Inspectors visited without notice on 23 February 2023. They spoke with the manager, nurses, care staff, administrators and a housekeeper. They observed care and reviewed care records, medicines records and management records.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse and avoidable harm, medicines were managed safely, staff were recruited safely and there were enough staff on duty during the visit.
Inspectors found strong management oversight and positive relationships with people, relatives and health professionals. However, some parts of the building needed maintenance, including damaged paintwork, woodwork, radiators and a cupboard area.
This was not a full review of all five areas. The Safe and Well-led ratings were assessed during this inspection. Ratings for the other areas were carried forward from the previous inspection when calculating the overall Good rating.
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding procedures and knew how to manage people's risks.
“People told us that they felt safe in the service and risks in relation to people's care were identified and managed to keep them safe.” from the report
Safe medicines practice
Medicines were ordered, stored and recorded safely. Staff had the skills to give medicines, including medicines taken when needed.
“People received their medicines in a safe way, as prescribed for them.” from the report
Good leadership
Inspectors found clear responsibilities, supportive management and effective systems for checking the quality of the service.
“The service had clear and effective governance systems in place.” from the report
Good partnership working
The home worked with health and social care professionals and made prompt referrals when people needed support.
“The service worked in partnership with health and social care professionals to ensure people received support to meet their needs.” from the report
Premises maintenance
needs fixingSome areas needed repair or redecoration. Inspectors found damaged paintwork and woodwork, damaged radiators and a damaged floor area where a cupboard had been removed.
“The safety and suitability of the premises were not always of a high standard.” from the report
Staffing pressure
minorInspectors saw enough staff during the visit, but staff said there could be times when the home was short-staffed. The home said gaps were filled by other staff.
“Staff told us there could be times when they were short of staff but that any gaps were filled in by other members of the staff team.” from the report
- 01Have all the damaged paintwork, woodwork, radiators and flooring identified by inspectors now been repaired?
- 02How do you check that there are enough staff on each shift, especially when there are staff gaps?
- 03What action do you take if a person’s care needs change during the day?
- 04How are relatives told about accidents, injuries or changes in a person’s needs?
- 05What were the previous ratings for Effective, Caring and Responsive, which were not assessed in this inspection?
This was an unannounced focused inspection of Safe and Well-led; the other key questions were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 31 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2022
Tregenna House was inspected but not rated; inspectors found good infection control and no reported impact from COVID-19 staffing pressures.
This was an announced, targeted inspection on 12 February 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected people.
Inspectors were assured that the home used protective equipment safely, arranged testing, followed cleaning and hygiene procedures, and managed infection risks. Staff absences linked to COVID-19 had not had a major impact on staffing levels or the support people received.
The home was following government visiting guidance during an outbreak. Essential care-giver visits and visits for people receiving end-of-life care were possible, while other visitors were temporarily not allowed.
The home was inspected but not rated. This means the report does not give an overall quality rating or ratings for most of the five questions.
Clear communication
The manager regularly explained procedures and precautions to people, staff and families.
“The registered manager was communicating with people, staff and family members regularly to make sure everyone had an understanding of procedures and precautions being taken, and how to keep people safe.” from the report
Infection control
Inspectors found systems for protective equipment, testing, cleaning and managing outbreaks. Extra cleaning and infection control measures had been introduced.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Staffing during the outbreak
COVID-19 absences had not had a major effect on staffing levels or the support people received.
“Staffing absences, due to COVID-19 infections had not had a mojor impact on the staffing levels or the quality of support people received.” from the report
Visiting arrangements
The home supported contact with relatives in line with guidance, including essential care-giver visits and visits for people receiving end-of-life care.
“People were supported to maintain contact with friends and family.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current visiting arrangements, including arrangements for essential care-givers and people receiving end-of-life care?
- 02How would you manage staffing if COVID-19 or other illness caused staff absences now?
- 03How often are residents and staff tested, and how is protective equipment used?
- 04What cleaning and infection control checks are carried out, and what happens if an outbreak occurs?
- 05How do you assess care quality in areas not covered by this inspection, such as medicines, care planning and people's day-to-day experiences?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other four questions were not assessed. This explanation was written from the published report of 9 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Tregenna House
4 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2022Inspected but not ratedSafe: Inspected but not rated
- January 2019Goodstayed GoodSafe: GoodWell-led: Good
- April 2018Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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