CQC report explained · a residential care home
What the CQC found at 4 Trinity Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risk assessments and medicines systems were generally in place, and staffing levels were judged sufficient. However, there was no night-time fire drill, inspectors were not confident about evacuation within two and a half minutes, and some recruitment records were incomplete.
- Effective?
- Good
- People's care, nutrition, hydration and healthcare needs were supported. Staff had supervision and training, but none of the 12 staff were fully up to date in all training areas because training places were limited.
- Caring?
- Good
- Staff showed kind and meaningful interactions. They supported people's privacy, dignity, communication, independence and individual choices.
- Responsive?
- Good
- People had individual lifestyle plans and took part in activities at home and in the community. Families were welcomed and feedback systems were in place, but end of life wishes were not fully recorded.
- Well-led?
- Good
- Inspectors found open leadership, positive staff morale and regular audits. The registered manager used feedback and checks to monitor the service and make improvements.
What inspectors found, September 2018
4 Trinity Court is rated Good; inspectors found caring, person-centred support, but identified gaps in staff training, night-time fire evacuation planning and some records.
This was an unannounced inspection on 7 and 8 August 2018. One inspector observed care, spoke with staff, relatives, an advocate and a local authority professional, and checked care plans, medicines records, staff files and audits. Some people could not speak directly with the inspector because of communication difficulties, so observations were also used.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were treated with kindness and dignity. Staff supported people's health, communication, choices, activities and contact with family and friends.
There were some areas to improve. Staff training was not always available quickly enough. Inspectors were not confident that people could be evacuated safely at night within the required time. One person's specific health need did not yet have a care plan and risk assessment, and some recruitment records were incomplete.
Kind and respectful care
Inspectors saw staff build positive relationships and treat people with dignity. Staff adapted their approach to people's communication and abilities.
“We observed staff interacting in a kind and meaningful way with people.” from the report
Choice and independence
People were supported to make choices and take part in their own care as far as possible. Their preferred communication methods and lifestyles were recorded.
“People were encouraged to be as independent as possible.” from the report
Activities and family contact
People had activities suited to their interests and abilities, both in the home and outside it. Families and friends were encouraged to stay involved.
“People participated in activities both in the home and in the wider community.” from the report
Positive leadership and monitoring
Staff and relatives described the management positively. Regular audits and feedback helped the home identify and make improvements.
“Audits were carried out to ensure the quality of the service met with expectations and were safe.” from the report
Night-time fire evacuation
seriousThere had been no night-time fire drills involving the people living in the home. Inspectors were not confident that the building could be evacuated safely at night within two and a half minutes.
“We were not confident based on what we read and what the registered manager told us the premises could be evacuated safely at night in the required two and half minutes.” from the report
Missing health risk assessment
seriousOne person had a specific health condition without a related risk assessment or care plan. Training and guidance were arranged during the inspection, but the report does not confirm that the new documents were completed.
“Without clear risk assessments people were in danger of receiving inappropriate or unsafe care.” from the report
Staff training availability
needs fixingNone of the 12 staff were fully up to date in all training areas. Some training sessions were oversubscribed, so staff were placed on waiting lists.
“We recommend the provider reviews the supply and demand for staff training to ensure there are sufficient numbers of suitably trained staff.” from the report
Recruitment records
needs fixingSome records for staff moving from bank work into permanent roles did not show complete employment histories or suitable professional references. The manager said missing information would be sought.
“We found records were not always consistent with safe employment processes in these instances.” from the report
End of life planning
minorCare plans did not contain enough information about people's end of life wishes. A management group was working on a suitable approach when inspectors visited.
“We noted in the care plans there was a lack of information for people regarding end of life care.” from the report
- 01Can you show us what has changed in the night-time fire evacuation procedure since this inspection, and have night-time drills now taken place?
- 02Was the missing health care plan and risk assessment completed, and how is it reviewed now?
- 03How do you make sure every staff member completes mandatory training on time when sessions are oversubscribed?
- 04How are employment gaps and professional references checked for bank staff who move into permanent jobs?
- 05How do you record and review each person's end of life wishes with their family or representative?
This was an unannounced inspection covering all five key questions and the overall rating; the inspector could not speak with all people living in the home because of communication difficulties. This explanation was written from the published report of 1 September 2018 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 4 Trinity Court
2 rated inspections over 3 years: the service has held its Good rating throughout.
- September 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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