CQC report explained · a nursing home
What the CQC found at Trevone House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improved risk management, safe medicines storage and recording, suitable staffing, safeguarding systems and infection control arrangements. They noted that protocols for some new and as-required medicines were not yet in place, and gave only some assurance about managing infection outbreaks.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- Inspectors found new audits, clearer records, better communication and systems for learning from incidents. They noted that some policies did not yet reflect the home's current working arrangements.
What inspectors found, March 2023
Rated Good; inspectors found safer, well-managed care, with a few medicines, infection control and policy points still needing attention.
This was an unannounced focused inspection on 9 and 10 February 2023. Inspectors checked whether the home had acted on problems found at the previous inspection. They reviewed care and medicine records, staff recruitment and training records, management documents, and infection control arrangements. They also spoke with relatives, staff and provider representatives.
The home had improved its risk assessments, medicines systems, infection control and checks on the quality of care. Staff had clear information about how to support the two young people, including their mental health needs and personal risks. Relatives said their family members felt safe and had made progress.
Inspectors rated Safe and Well-led as Good. They found some smaller shortfalls. Protocols for some new and as-required medicines were not yet in place, the home was only somewhat assured about managing infection outbreaks, and some policies needed updating.
The overall rating changed from Requires Improvement to Good. The previous breaches of Regulations 12 and 17 had been addressed, and the home was no longer in breach. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Improved risk support
Risk and support plans had been reviewed and gave staff clear guidance about each young person's risks, mental health and agreed support strategies.
“Staff had access to each person's risk and support plans.” from the report
Safer medicines systems
Medicines were securely stored, managed and checked. Records of prescribed medicines had no gaps.
“Medicines were securely stored, managed and accounted for.” from the report
Skilled and suitable staff
Inspectors found enough suitably qualified staff. Agency staff were familiar with the young people, and recruitment checks and training were in place.
“There were sufficient numbers of suitably qualified staff to meet young people's needs at Trevone House and to support them to stay safe.” from the report
Better oversight
The home had introduced audits and checks covering care, medicines, emergency equipment, the building and staff support.
“The registered manager had developed and implemented a range of audits which enabled them to assess, monitor and improve the quality and the safety of the service being provided.” from the report
Positive progress
Relatives praised the progress made, including educational and housing progress. Inspectors also saw examples of personal goals being reached and fewer self-harm incidents.
“Young people's relatives praised the progress that their family member had achieved at Trevone House including educational and housing.” from the report
Infection outbreak planning
needs fixingInspectors were only somewhat assured that the home could prevent or manage an infection outbreak effectively. They directed the provider to resources about what staff should do when an outbreak is suspected or identified.
“We were somewhat assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Policies being updated
minorSome policies did not fully reflect the home's current working arrangements. The provider said it had plans to review them.
“The provider had recognised their policies did not fully reflect the recent changes in the working arrangements at Trevone House.” from the report
- 01Have the personalised instructions for as-required medicines and medicines prescribed during a medicine cycle now been completed?
- 02What would staff do if an infection outbreak was suspected, and have they received the guidance referred to by inspectors?
- 03Have all policies been updated to reflect the home's current working arrangements?
- 04How are weekly audits and incident reviews shared with families and the professionals involved in a young person's care?
- 05How does the home measure progress towards each young person's mental health, education and housing goals?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection and were used to calculate the overall rating. This explanation was written from the published report of 14 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, July 2022
Rated Requires Improvement; inspectors found kind, personalised support but weaknesses in safety, medicines and quality oversight.
This was the home’s first inspection since it registered. It was unannounced and took place on 9 June 2022. One inspector spoke with relatives and staff, reviewed care and medicines records, and checked recruitment, training and management records.
Inspectors found that young people received kind, respectful and personalised support. Staff helped them work towards goals such as education, employment, independence and managing their mental health. Relatives spoke positively about the staff and said communication had improved.
However, the home was not always safe or well-led. Risk assessments, care plans and medicines records were not always clear or complete. Infection control arrangements were not in line with guidance, and checks on care quality were not effective.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. The report says there was an increased risk that people could be harmed.
Kind and respectful staff
Relatives praised the staff and the home’s approach. Inspectors found that young people were treated respectfully and without judgment.
“Relatives praised the ethos of the service and the kindness of staff.” from the report
Personalised support
Staff provided support based on each young person’s mental health needs, preferences and goals. They helped young people develop coping skills and work towards greater independence.
“Through the dedication of staff and model of care being provided, young people had been supported to reflect on their experiences, develop coping strategies and to work towards their individual goals.” from the report
Good partnership working
The home worked with mental health teams, the council and other professionals to support continuity of care and referrals.
“The service had formed good links with key and specialist professionals and stakeholders.” from the report
Support for daily life
Young people were supported with activities, education, employment, meals and daily living skills.
“Young people were supported to progress into independent living and be more active in taking responsibility of daily living tasks such as planning and preparing meals and drinks.” from the report
Infection control
seriousThe home did not have all the required infection control arrangements in place. Inspectors found problems with COVID-19 testing, personal protective equipment, policies and outbreak planning.
“Effective infection control measures had not been put into place putting people at risk of harm and the spread of infection.” from the report
Risks and care records
seriousStaff did not always have current risk assessments, risk management plans or complete care plans to guide support when a young person’s mental health declined.
“Staff did not have access to current assessments and risk management plans to help them understand the current risk for each young person and how they should be supported during a decline in their mental health and associated risks.” from the report
Medicines management
seriousMedicine care plans and instructions for medicines given when needed were not clear. Records included unknown codes, so the manager could not be sure whether medicines had been given or refused.
“Therefore, the manager could not be assured that young people had received or refused their medicines as medicines administration records (MARS) had not been accurately completed.” from the report
Quality oversight
seriousThe provider’s checks were not effective enough to identify and fix problems with care, records, medicines, staff skills, infection control and fire safety.
“Effective quality assurances and governance systems had not been implemented to assess and monitor the quality of the service.” from the report
Agency staff skills
needs fixingThe provider had not assured itself that agency staff had the skills and competence needed to support young people with complex mental health, physical and medicines needs.
“The provider had not ensured themselves that the agency nurses were competent in their role to support people with complex mental health needs and physical and medicines needs.” from the report
- 01What immediate changes have you made to medicines records, including instructions for medicines given when needed?
- 02How do you now make sure staff have current risk assessments and care plans, especially when a young person’s mental health changes?
- 03What infection control, COVID-19 testing, protective equipment and outbreak plans are currently in place?
- 04How do you check that agency nurses and other agency staff are trained and competent to support young people with complex needs?
- 05What quality checks are now in place, and what progress has been made in response to the CQC warning notices?
This was the first comprehensive, unannounced inspection of the newly registered home and covered all five CQC questions, including infection control and the care provided. This explanation was written from the published report of 21 July 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 Trevone House
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2021
Registered with the Care Quality Commission on 27 April 2021.
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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38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.