CQC report explained · a residential care home
What the CQC found at Trevella House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. There were enough staff, medicines were given safely, and risk assessments guided staff.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Records were difficult to access and there was no contingency plan if electronic systems were unavailable. Audits identified some medicines-record errors but did not show clearly how these were addressed.
What inspectors found, August 2023
Rated Good overall; inspectors found safe care, but the home’s leadership and record systems still require improvement.
This was an unannounced, focused inspection of Safe and Well-led. Inspectors visited on 6 and 20 June 2023, spoke with people, a relative and staff, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, suitable risk assessments, safe medicines practice and safeguarding arrangements. People told inspectors they felt safe.
The home was rated Requires Improvement for Well-led. Records were not well organised or always easy to access. Audits identified some medicines-record errors but did not clearly show what action had been taken.
The overall rating stayed Good because the other three question ratings were carried forward from the previous inspection in 2019. Only two people were receiving personal care at the time of this inspection.
Safe medicines
Inspectors found that people received their medicines safely and as prescribed. Staff who administered medicines were trained and had competency checks.
“People received their medicines safely and as prescribed and were supported by sufficient numbers of staff to ensure that risk of harm was minimised.” from the report
Enough suitable staff
Staff recruitment checks had been completed, including references and DBS checks. Inspectors observed enough staff to meet people’s care needs.
“All pre-employment checks had been carried out including reference checks from previous employers and Disclosure and Barring Service (DBS) checks.” from the report
Managing risks
People had risk assessments and personal emergency evacuation plans. Staff understood safeguarding procedures and how to protect people from harm.
“There were robust risk assessments in place to guide staff to how they should support people safely.” from the report
Positive relationships
People and relatives spoke positively about the care. Staff were described as committed to providing care tailored to people’s needs and preferences.
“People and their relatives spoke positively about the care they received and of the way the service was run.” from the report
Records were hard to access
needs fixingSome records were on paper and others were electronic. Staff could not always find records promptly, and there was no printed backup of people’s care needs if the electronic system was unavailable.
“The providers filing systems were not well organised. During our inspection visit staff were unable to locate some records we requested.” from the report
No clear action after audit findings
needs fixingMedicine audits found missing signatures on some records, but there was no formal action plan showing how these issues were dealt with.
“However, there was no action plan for how any identified issues were formally addressed.” from the report
- 01What has the home done to make paper and electronic records easier to organise and access?
- 02What backup information is available if the electronic care-record system is unavailable?
- 03How are missing signatures or other medicines-record errors now followed up and recorded?
- 04Who will provide consistent on-site management while the new registered manager application is considered?
- 05What changes have been made since the previous inspection to improve the Well-led rating?
This was a focused inspection of Safe and Well-led; the other three ratings were carried forward from the previous inspection in 2019. This explanation was written from the published report of 4 August 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, September 2019
Rated Good overall, but inspectors found the home was not always well-led because audits and records needed improvement.
This was an unannounced inspection on 19 July 2019. The inspector spoke with four people, three staff members and reviewed care plans, medicines records, recruitment and management records.
People were found to be safe, supported and treated with kindness and respect. Staff understood safeguarding, there were enough staff, medicines were generally given as prescribed, and people were supported with food, health appointments, activities and independence.
The home was rated Good for Safe, Effective, Caring and Responsive. Well-led was rated Requires Improvement because quality checks did not always identify problems, medicine records were sometimes incomplete, and records were not well organised.
The overall rating improved from Requires Improvement at the previous inspection. The earlier breach about medicines audits had been resolved, although further work was still needed.
People felt safe
People told inspectors they felt safe and well supported. Staff understood safeguarding and how to report concerns.
“People continued to tell us they felt safe and well supported.” from the report
Kind and respectful care
People were treated with compassion, dignity and respect. Inspectors observed positive, professional interactions between staff and people.
“People were treated with compassion by a caring and respectful staff team.” from the report
Good support and training
Staff received training linked to people's needs and were able to support their roles effectively. People were helped to attend health appointments and manage their wellbeing.
“Staff received training that was appropriate to them in their role and supported them in providing care in the way people wanted.” from the report
Choice and independence
People were involved in decisions, encouraged to remain independent and supported to follow hobbies, attend courses and maintain relationships.
“People were supported to have maximum choice and control of their lives” from the report
Medicine records
needs fixingSome medicine records had not been signed. The use of two separate records for each person made it harder to confirm administration quickly.
“There were some instances where staff had not signed the medicine record.” from the report
Quality checks
needs fixingThe home's audits did not always identify shortfalls consistently. The provider said audits would be carried out every two weeks.
“Quality assurance systems were in place but needed further development to ensure they consistently identified shortfalls.” from the report
Poorly organised records
needs fixingSome records were paper-based and others electronic. Records were often difficult to find during the inspection, which delayed access to information.
“Filing systems were not well organised.” from the report
Ligature-risk assessment
needs fixingInspectors said the risk assessment process for ligature risks needed improvement. Information received after the inspection showed this was being addressed.
“Improvement was needed to the risk assessment process for ligature risks.” from the report
- 01What changes have been made to ensure every medicine administration is signed and checked?
- 02Are medicine records now kept in one clear system rather than two separate records?
- 03How often are quality audits carried out now, and how are problems followed up?
- 04How have paper and electronic records been organised so staff can find them without delay?
- 05What action was taken to improve the assessment of ligature risks?
This was an unannounced planned inspection covering all five CQC questions, with the overall rating based on the findings from the visit. This explanation was written from the published report of 3 September 2019 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 Trevella House
4 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2015
Registered with the Care Quality Commission on 12 January 2015.
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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