Trelowen Manor

This key question was previously rated good. At this assessment the rating has changed to inadequate. We identified 6 breaches of regulation. This meant people were not safe and were at risk of avoidable harm. People were at risk of not receiving safe care because risks to people’s health and safety were not adequately assessed and action was not taken to mitigate risk. The service did not have effective systems to ensure incidents and risks were analysed effectively and action was taken to prevent re-occurrence. The provider had failed to respond sufficiently to previous incidents of harm. The provider had not always identified or appropriately reported incidents of abuse, neglect and improper treatment. Staff were not complying with the principles of the Mental Capacity Act, 2005 which was leading to unlawful restrictions on people. People were not protected from being cared for by unsuitable staff and there were not enough staff to keep them safe. Staff lacked the skills and knowledge to keep people safe. People were not safe from infection control risks and the environment they lived in was not safe.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread shortfalls in leadership. Leaders and the culture they created did not assure delivery of high-quality care. The provider was in breach of legal regulations in relation to good governance. Governance systems were not effective in identifying the concerns we identified during this assessment. The provider and manager did not have the skills, knowledge and understanding they needed to deliver a service that provided safe care and treatment to people living at the service. Whilst staff told us they felt better supported under the new provider, we found the culture of the service was not positive. We observed care that people received was task focused and not personalised. The provider did not have processes to demonstrate they listened to and acted upon concerns. Despite working with partner agencies to make improvements, the provider had not made enough improvement. and the service was not safe for people.