This unannounced comprehensive inspection was carried out on 19 July 2018. During our last comprehensive inspection on 11 July 2017 we rated the service requires improvement as they were not meeting the required standards. On 07 February 2018 we carried out a focused inspection to check that improvements to meet legal requirements planned by the provider after our inspection on 11 July 2017 had been made. The team inspected the service against two of the five questions we ask about services: Is the service well led, and is the service safe? Following the focused inspection, the rating remained requires improvement. Further improvements were needed to achieve Good rating. At this inspection we found that they were meeting the standards.

Trembaths is a ‘care home’. 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.

Trembaths is registered to provide personal and nursing care for up to 51 older people, including people living with dementia. At the time of the inspection there were 46 people living there.

The service had a manager who had applied to be registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 and associated Regulations about how the service is run.

The manager had been in post since March 2018 and they had been quick in identifying all the areas which needed improving for people to receive a good service. We saw that they were actively supporting staff on the floor, coaching and mentoring them to ensure staff delivered personalised care and support and were not task led.

Staff were trained and supported to carry out their roles effectively. They gave us positive feedback about the manager and their approach towards them, people and relatives.

People told us they felt safe at the home and they were cared for by staff who were kind and protected their privacy and dignity. However, people and relatives reported that at times staff turned call bells off promising they would be back soon to meet peoples` needs but waiting times had been up to 15 minutes on occasions. They also told us that there were times when they felt there was a shortage of staff. The manager had identified these issues and carried out observations and updated people`s dependency assessments to ensure at all times there was sufficient numbers of staff allocated to meet peoples` needs. They also observed staff answering call bells and monitoring if staff met people`s needs in a timely way.

Staff showed an understanding of safeguarding and issues of consent and capacity. They were aware of preventing and recognising the different types of abuse and neglect and told us they would feel confident reporting concerns to the manager and external safeguarding authorities.

People`s medicines were administered safely by trained staff who had their competencies checked. There were processes in place to deal with emergencies and staff were knowledgeable about these.

Staff were aware of the need to assess and manage risks whilst allowing people freedom to make choices about their lives. There were risk assessments in place for any identified risk to people`s well-being.

Staff adhered to the principles of the Mental Capacity Act 2005. People had regular access to health and social care professionals. People enjoyed a variety of foods and the mealtime experience observed was positive.

People and relatives told us that staff were kind. People shared mixed views about whether they were involved in planning their care. Confidentiality was promoted and there were regular links to the community.

New care plans were being rolled out by the p

This unannounced inspection was carried out on 07 February 2018. During our last inspection in July 2017 we rated the service as requires improvement. Following this inspection the rating remains requires improvement. This was because, although we saw improvements had been made following the last inspection, these improvements have not yet been fully embedded within the culture of the service. We also found some additional aspects of the service which required action before the service could be rated as good.

Trembaths is a ‘care home with nursing’. 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.

Trembaths accommodates up to 51 people in one adapted building across two separate units, each of which have separate adapted facilities. One unit is for people with nursing needs and the second is for people with residential needs including people who live with dementia. At the time of the inspection there were 41 people living at the home.

Since the last inspection the registered manager had left the service and one of the provider’s area support managers was acting into the role until such time as a permanent manager was recruited. The area support manager (acting manager) had commenced the process to register. 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.

Following the last inspection, we met with the provider to confirm what they would do and by when to improve the key questions Safe, and Well led to at least good. A condition was placed on the provider’s registration requiring them to provide monthly reports on their progress towards meeting the required standards. The provider also submitted an action plan showing what action they would take and by when to address the concerns identified at the inspection.

This inspection was done to check that improvements to meet legal requirements planned by the provider after our July 2017 inspection had been made. The team inspected the service against two of the five questions we ask about services: Is the service well led, and is the service safe? This is because the service was not meeting some legal requirements within these two questions.

No risks or concerns were identified in the remaining key questions through our ongoing monitoring or during our inspection activity, so we did not inspect them. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection

There were systems and processes in place to safeguard people from harm, and incidents were reported appropriately. When mistakes were made by the provider or staff, these were acted on, lessons were learned and improvements were made.

The provider had policies and systems in place to protect people from the risk of infection. However, some staff did not always follow good practice in relation to infection control.

Medicines were not always managed safely. The provider was aware of this and was taking appropriate steps to improve this and reduce the risk of harm to people.

There were sufficient staff to support people safely although the way in which work was organised sometimes resulted in delays in meeting people’s needs. The provider had effective recruitment processes in place.

There were risk assessments in place that gave guidance to staff on how risks to people could be minimised and these were regularly reviewed and updated when people’s needs changed.

The provider encouraged feedback from people and acted on the comments received to continually improve the qua

This inspection was carried out on 11 July 2017 and was unannounced. At their last inspection on 20 December 2016, they were found to not be meeting the standards we inspected. At this inspection we found that they had continued to not meet all the standards.

Trembaths provides accommodation for up to 51 older people, including people living with dementia. The home is registered to provide nursing care. At the time of the inspection there were 50 people living there.

The service had a manager who was applied to be registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 and associated Regulations about how the service is run.

Systems in place to monitor the quality of the service did not identify shortfalls in some areas. This impacted on the safety and welfare of people and the quality of the service provided. We also found that the feedback about the management was mixed.

People were not always protected from the risk of harm as accidents, incidents and unexplained injuries were not sufficiently reviewed for themes, investigated or reported.

Staffing levels did not always meet people’s needs. However staff were recruited through a robust process.

People were supported by staff who were trained, and although staff felt supported, they did not receive regular one to one supervision.

Staff adhered to the principles of the Mental Capacity Act 2005. People had regular access to health and social care professionals. People enjoyed a variety of foods and the mealtime experience observed was positive. People’s medicines were managed safely.

People and relatives told us that staff were kind. People shared mixed views about whether they were involved in planning their care. Confidentiality was promoted and there were regular links to the community.

People’s care plans were clear and included person centred information. People’s care needs were met, however this was not consistently in a person centred way. People enjoyed a variety of regular activities and formal complaints were responded to.

We carried out an comprehensive inspection of this service on 19 July 2016 where breaches of legal requirements were found. After this inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to safeguarding people from abuse, management of medicines, person centred care and governance systems in place to address any shortfalls identified.

We undertook this unannounced focused inspection on 20 December 2016 to check that they now met legal requirements. This report only covers our findings in relation to those requirements. We checked if the service was safe, responsive and well led. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Trembaths on our website at www.cqc.org.uk

Trembaths provides accommodation, care, nursing and support for up to 51older people, some of whom are living with dementia. At this inspection 48 people were living at the service.

There was a manager in position however they were not registered. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

At the previous inspection we found that people did not always receive person centred care. Staff were busy and this resulted in a task orientated approach towards people`s needs, and at times staff spoke abruptly with people. This did not promote people`s dignity or respect. At this inspection we found staff were knowledgeable about people`s preferences and the care people received was personalised around their wishes, however more improvements were needed to address negative staff culture and attitude towards people.

At the previous inspection people and staff told us that they felt there were not enough which meant that people often had to wait for care. At this inspection we found although this has improved further improvements were required in how staff were deployed around the building to meet people`s needs promptly.

The manager and the provider implemented new governance systems to enable them to monitor the quality and the safety of the care provided to people. However these were not fully operational and robustly embedded.

People`s care plans were clear and reviewed monthly, however not all the care plans evidenced people`s involvement or their family`s input in creating them or in the reviews.

When we previously inspected the service people told us that the food provided to them was not to their liking and we observed that people had not received sufficient support with eating and drinking. At this inspection we found that people were provided with sufficient food and drinks and appropriate assistance was given to people who needed help with eating and drinking. People still expressed mixed views about the quality of the meals.

At the previous inspection we found that where people had unexplained bruises these were not investigated and in some instances the local authority safeguarding process was not adhered to. At this inspection we found that this improved and all incidents and accidents were investigated and where necessary reported to local safeguarding authorities. People’s medicines were managed safely and records were accurate.

The feedback about the manager was positive and staff felt supported. There was a range of activities available and people were involved in planning these. People knew how to make a complaint and we saw these were responded to.

This inspection was carried out on 19 July 2016 and was unannounced. When we last inspected the service on 29 June 2015 they were found to be meeting all the standards we inspected. However some areas required improvement. At this inspection we found that they were not meeting all the standards. This was in relation to safeguarding people from abuse, management of medicines, person centred care and the systems in place to address any shortfalls identified.

Trembaths provides accommodation, care, nursing and support for up to 51older people, some of whom are living with dementia. At this inspection 50 people were living at the service.

The service did not have a registered manager in post and the service was being managed by an interim manager employed by the provider. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

Where people had unexplained bruises, these had not been investigated at the time of our inspection. However, following our inspection, these were carried out. We also found that in some instances the local authority safeguarding process was not adhered to. People’s medicines were not always managed safely and records were not accurate. At times this meant people did not receive their medicines in accordance with the prescriber’s instructions.

People did not always receive person centred care. Staff were busy and this resulted in a task orientated approach and people`s care needs were not met promptly. People told us that staff were mostly nice but there were times when they were abrupt because they were busy. This did not promote people`s dignity or respect. People and staff told us that they felt there were not enough staff and this meant they often had to wait for care. Staff received appropriate training for their role and had regular one to one supervision. The service was planning to develop staff and introduce champions for specific areas.

Systems in place that had identified some of the issues found on inspection had not been effective in resolving these. The feedback about the interim manager was positive and staff felt supported.

There was a range of activities available and people were involved in planning these. However, they were not consistently involved in planning their care and support needs. Care plans were clear and in most cases reviewed monthly. People knew how to make a complaint and we saw these were responded to.

This inspection was carried out on 9 June 2015 and was unannounced.

Trembaths provides accommodation and personal care for up to 51 older people and provides nursing care. There was a registered manager in post. 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 and associated Regulations about how the service is run.

When we last inspected the service on 25 June 2014 we found them to not be meeting the required standards and they were in breach of regulations 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to regulations 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found that they had met the standards.

Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection applications had been made to the local authority in relation to people who lived at the service and were pending an outcome. Staff were aware of their role in relation to MCA and DoLS and how people were at risk of being deprived of their liberty.

People thought that overall their needs were being met. There was some feedback relating to staffing and waiting times. However, during the inspection we found that people’s needs were met in an appropriate timeframe.

Staff had received training and had regular supervision. The home followed robust recruitment procedures. The manager was new to the home and was working through a plan to continually improve the service. Staff felt they were approachable and were positive about their leadership.

Risks to people’s safety and welfare were assessed and staff were aware of their individual needs. Medicines were managed safely and people had regular access to health care professionals. Care plans contained clear guidance for staff to follow on how to support people and people’s individual preferences were reflected in these plans. Privacy was promoted and people felt that they were listened to. Staff were recruited through a robust procedure and provided with regular training to ensure their knowledge was up to date. Staff were clear on their role. People and staff were positive about the manager and their leadership.

We set out to answer five questions. These were whether the service is caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service and the staff that supported them. We also spent time looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that care was planned and delivered in a way that was intended to ensure people’s safety and welfare.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Where applications had needed to be submitted, proper policies and procedures had been followed. Relevant staff had been trained to understand when an application should be made, and how to submit one.

We found that the service was required to make improvements in relation to safeguarding people from the risk of abuse.

The service followed appropriate recruitment procedures to ensure staff were of good character and had suitable experience and skills for the role.

Is the service effective?

We saw that the risk assessments and support plans in people’s care plans had been reviewed and updated on a monthly basis.

We looked at the care notes for people whose plans we had viewed and saw that care was recorded as being delivered in accordance with the plans.

We also looked at accident and incident forms. We found that where there were unexplained bruises and skin tears, these had been fully investigated.

People were supported in accordance with their needs and their care plans in relation to receiving sufficient nutrition and hydration.

Is the service caring?

We observed staff interaction with people who used the service and noted that interactions were positive. Staff were attentive. We spoke with people who used the service and they told us that staff were kind.

Is the service responsive?

We found that the service responded to its internal audits and developed action plans. There was a record of these actions being completed. Meeting notes, complaints and survey analysis that we viewed demonstrated that the service had responded appropriately to feedback.

Is the service well led?

The home was being run by a peripatetic manager until three weeks prior to our inspection. A peripatetic manager is a manager brought into a service by the provider to cover the vacancy of a permanent manager and resolve any ongoing issues. A new manager had recently started in post. We found that areas they had identified in relation to the quality of the service were being addressed and were still in progress. We spoke with staff who felt that the peripatetic manager had made a difference to the service and felt they had made a positive impact on the staff team.

During our inspection we spoke with a number of people who lived at Trembaths, as well as with relatives who were visiting the home. People told us they were happy at Trembaths. One person said “Excellent care, excellent home.”

People were treated in a professional, caring way by the staff, who encouraged people to be as independent as possible. People said that their privacy and dignity were respected by the staff.

Care records gave staff the guidance they needed to meet people’s needs and people saw other healthcare professionals so that their health was monitored. Infection prevention and control procedures and practices meant that the home was kept clean and smelt fresh in most areas. Staff were aware of their responsibilities to follow the procedures, and to use the equipment available, so that the risk of infection was minimised.

Medicines were managed well, which meant that people received their medicines safely and as they were prescribed.

Staff had undertaken a wide range of training so that they were equipped well to carry out their role, and they told us they felt well supported by their line managers. People were very complimentary about the staff. A relative described the staff as, “Brilliant, wonderful. I have no complaints. They tell me what’s going on and treat [my family member] with respect.”

People we spoke with knew how to complain if they needed to and the manager showed us that a log was kept of all complaints and compliments received.

We visited the home on 17 and 31 August 2012 and spoke with four people who lived there and the relatives of four other people. All told us that they felt their, or their relative’s needs were met by the staff. One person told us they were, “Made very welcome on arrival and they look after me very well.”

One relative told us their relative was, “Very, very well looked after and always spotlessly clean”, another told us their relative, “Couldn’t be cared for more”. One relative commented on the, “Enormous amount of work” staff had done to heal their relative’s sores and to maintain their skin condition.

During our visit we saw staff providing care and support to people living at the home. The staff gave people time to communicate and did not rush them; they spoke in a calm and respectful way, varying their approach according to the person they were assisting.

People told us that staff had the skills and knowledge to meet their needs. The relative of one person told they had seen some, “Excellent” and, “Exemplary” staff, who had a real understanding of their relative’s needs. Another relative told us that they thought staff, “Empathised” with the people living at the home and said, “They are marvellous”. A third relative told us, “Nothing is too much trouble [for the staff].”

People told us that they felt safe and trusted the majority of the staff and the Registered Manager of the home. They said the majority of staff treated them in a respectful manner. However, three people told us that that this was not the case with all staff. We saw that where this had been reported to the Registered Manager they had taken the matter seriously and the person told us that the situation had improved.

People living at the home told us the Registered Manager had responded to any concerns that they had raised. People who had not had cause to raise concerns were confident that the Registered Manager would address anything they raised.

The relatives of people living in the home told us that they felt involved in decisions about the care provided. They said the staff kept them, “Well informed” of their relative’s condition. Two relatives told us they felt the staff, “Looked after” them as well as their relative, and that staff had been considerate of their feelings when imparting information. This contributed to their confidence in their family member’s safety.

People talked about, and we saw, there was opportunity to be involved with a wide range of activities. One person told us, “There’s always something going on” and told us about parties, trips out and regular group activities. During our visits we saw that care workers encouraged and involved people living at the home in group and one to one activities, paying attention to people’s differing needs.