CQC report explained · a residential care home
What the CQC found at Tregolls Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that medicines, risk assessments, safeguarding systems, staffing and infection control were managed safely. They also found that people had suitable support to make decisions and that required authorisations were in place.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- Care plans described people's needs, routines and preferences and were reviewed regularly. People were supported with communication, activities, visitors and complaints.
- Well-led?
- Good
- Inspectors found better management oversight, accurate and secure records, improved reporting of incidents and regular checks on service quality. People, relatives and staff were positive about the management team.
What inspectors found, October 2022
Tregolls Manor is rated Good; inspectors found safe, responsive and well-led care after improvements since the previous inspection.
Inspectors visited unannounced on 29 September 2022. They spoke with people living in the home, relatives, staff and a health and social care professional. They reviewed care plans, medicine records, recruitment information and management records.
The home was rated Good overall, with Good ratings for Safe, Responsive and Well-led. People said they felt safe and well cared for. Inspectors found medicines were managed safely, staffing levels were suitable, care records had improved and the home was clean.
This was a focused inspection. It checked whether earlier problems with medicines, reporting incidents and management systems had been fixed. The home had previously been rated Requires Improvement, but inspectors found the provider was now meeting the relevant regulations.
Safer medicines management
The earlier problems with medicine records, admission checks and follow-up when medicines were declined had been addressed. Monthly audits were being used to check medicines management.
“At this inspection we found that medicines were checked on the persons admission and that they were recorded correctly.” from the report
Suitable staffing
New staff had been recruited and reliance on agency staff had reduced. Inspectors found enough staff on duty and people were supported by regular staff who knew them.
“This meant that people were cared for by consistent staff that knew them well.” from the report
Personalised care
Care plans included people's needs, routines, preferences and communication requirements. People were involved in creating and reviewing their care plans.
“Staff followed care plans to deliver care and support which was individualised to each person's needs.” from the report
Improved leadership
The management team had improved audits, records, incident reporting and action planning. Records were stored securely and management checks were taking place.
“The registered manager had addressed all the issues highlighted in the previous report.” from the report
Some medicine guidance was still being reviewed
needs fixingGuidance for medicines given when needed was still being reviewed. Ask how this work was completed and how staff know when to offer or give these medicines.
“As required protocols were being reviewed so that staff had guidance for when these medicines needed to be administered.” from the report
- 01How are you making sure guidance for medicines given when needed is complete and clear for every person?
- 02How do you record the events that may cause my relative anxiety and the support staff should provide?
- 03What staffing levels are planned for the shifts when my relative would usually need the most help?
- 04Which activities would match my relative's interests, communication needs and ability to take part?
- 05How will you tell families about any incidents, complaints or changes in their relative's care?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried over when calculating the overall rating. This explanation was written from the published report of 13 October 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.
What inspectors found, October 2021
Tregolls Manor was rated Requires Improvement; inspectors found kind care and enough staff, but serious weaknesses in medicines, records and reporting incidents.
This was an unannounced focused inspection on 7 September 2021. Inspectors checked Safe, Effective and Well-led because of concerns about staffing, medicines and how management responded to issues. They spoke with people, staff and relatives, observed care, and checked care, medicine, staff and management records.
People said they felt safe and that staff were kind. Inspectors found enough staff on duty, including regular agency staff, and found good support with food, drinks and healthcare. Staff recruitment checks and training were also satisfactory.
However, medicine records did not always match the medicines in stock or the instructions on medicine packages. Staff did not always follow up missed medicines, and guidance for medicines given when needed was incomplete. Risks and changing needs were not always transferred into care plans, and confidential records were left in public areas.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective remained Good. Caring and Responsive were not inspected during this visit, so earlier ratings for those areas were used in the overall assessment.
Kind and respectful care
People and relatives spoke positively about the care. Inspectors also saw kind interactions and staff who knew people well.
“People using the service consistently told us they felt safe and that staff were caring and respectful.” from the report
Staffing cover
There were permanent staff vacancies, but regular agency staff covered the vacant shifts. Rotas showed that staffing was sufficient for people's needs at the time of inspection.
“Staff rotas confirmed that sufficient staff were on duty at all times to meet people's current needs.” from the report
Food and drinks
People enjoyed the food and were offered regular drinks. Staff understood people's dietary needs and preferences.
“People were complimentary about the food and drinks available.” from the report
Healthcare support
People could access health professionals, and staff responded to changes in people's health. Inspectors saw staff act on advice from a district nurse.
“People had access to GP's, dentists and other healthcare professionals.” from the report
Medicine management
seriousMedicine stock and records did not always agree. Instructions could be unclear, missed medicines were not always followed up, and guidance for medicines given when needed was incomplete.
“This led to confusion as to the timings and dosage of when medicines were to be administered which could potentially lead to a person being over or under medicated.” from the report
Care plans and risk information
needs fixingIdentified risks and changes in people's needs were not always added to care plans. This could result in people receiving inconsistent support.
“Care plans were reviewed but when people's needs had changed, they were not always updated on the person's care plan.” from the report
Privacy of records
needs fixingCare records were still being left in public areas where people living in, working in or visiting the home could access them. This problem had also been raised at the previous two inspections.
“We continued to find people's care records in public areas and accessible to all.” from the report
Incident reporting
seriousThe home had not told CQC about some incidents, including falls or occasions when people needed medical attention. Inspectors said the provider was not open and transparent about incidents and learning from them.
“The registered provider has failed to notify us without delay of incidents they are required legally to inform us of.” from the report
- 01What has changed in the way you check medicine stock, medicine records and instructions when someone moves in?
- 02How do you now follow up and report repeated refusals of medicines?
- 03How are risks and changes in people's needs transferred promptly into their care plans?
- 04Where are care records kept now, and how do you prevent unauthorised access?
- 05What system now ensures falls and incidents needing medical attention are reported to CQC without delay?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 15 October 2021 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 Tregolls Manor
6 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodstayed GoodSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodSafe: Good
- August 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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