CQC report explained · a nursing home
What the CQC found at Trinity Court Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, thorough recruitment checks, safe medicines practice and up-to-date risk assessments. Infection control arrangements, including COVID-19 testing, PPE, cleaning and isolation, were also found to be suitable.
- Effective?
- Requires improvement
- This question was not covered by this focused inspection, so no new rating was given in the report.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People and their relatives were involved in care planning, although some sections of the personal information were not always completed.
- Responsive?
- Good
- Care plans covered people's needs, preferences and communication. The home supported contact with relatives during the pandemic, responded to complaints and recorded end of life wishes.
- Well-led?
- Good
- The home had regular audits, action plans and systems for learning from incidents. Feedback described an open culture, accessible management and good partnership working with healthcare professionals.
What inspectors found, February 2021
Trinity Court Nursing Home is rated Good overall; inspectors found safe, caring and responsive care, with improvements since the last inspection.
This was an unannounced focused inspection on 21 January 2021. Four inspectors spoke with relatives, staff, managers and healthcare professionals. They reviewed care plans, medicines records, recruitment files, rotas, complaints, policies, audits and training records.
The home was rated Good for Safe, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment checks, suitable medicines arrangements and good infection control during the COVID-19 pandemic. People were treated with kindness, dignity and respect, and care plans reflected their needs and preferences.
The home had previously been rated Requires Improvement, with breaches relating to staff recruitment, person-centred care and governance. Inspectors found that improvements had been made and that the home was no longer in breach of those regulations.
Inspectors did note that some sections of people's personal information were not always completed. They recommended that the home continued to make care plans more personalised.
Staffing and recruitment
Inspectors found enough staff on duty and thorough checks on new staff. Staff were present throughout the home and responded quickly when people asked for help.
“People now received care and support from staff whose suitability and fitness to work in a care home had been thoroughly assessed.” from the report
Infection control
The home had arrangements for PPE, testing, cleaning, isolation and zoning during the pandemic. Inspectors saw staff using PPE correctly and found the premises hygienically clean.
“We were assured the service was following safe infection prevention and control (IPC) procedures, including those associated with COVID-19.” from the report
Kind and respectful care
Inspectors saw staff supporting people patiently and with warmth. Relatives said staff respected people's dignity and encouraged their independence.
“People looked at ease and comfortable in the presence of staff throughout out inspection and conversations between people and staff were characterised by kindest and warmth.” from the report
Family involvement and communication
Relatives were involved in care planning and were kept informed during visitor restrictions. The home supported phone, video and other forms of contact with family and friends.
“Alternative arrangements had been developed to help people maintain social contact with their family members and friends during this pandemic.” from the report
Improved management
The home had strengthened its audits and action plans since the previous inspection. Inspectors found an open culture and evidence that incidents were used to improve care.
“There was evidence the provider used this as a learning tool to make improvements to practice or to minimise the incidents from occurring in future.” from the report
Some care plan information was incomplete
minorInspectors found some inconsistency in completing all sections of the personal 'Who am I?' information. They recommended that the home continued to make care plans more personalised.
“It was noted that there was some inconsistency in completing all sections of the 'who am I' information.” from the report
- 01How do you make sure every section of my relative's 'Who am I?' information is completed and reviewed?
- 02How will you involve me and my relative in reviewing the care plan?
- 03What visiting and other contact arrangements are currently available for relatives?
- 04How do you check that staffing levels continue to meet people's changing needs?
- 05How would you manage an infection outbreak and keep families informed?
This was a focused inspection covering Safe, Caring, Responsive and Well-led, with infection prevention and control included under Safe; the report says ratings for key questions not examined were carried over from the previous comprehensive inspection. This explanation was written from the published report of 9 February 2021 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, June 2019
Rated Requires Improvement; inspectors found people often felt safe and cared for, but records, recruitment and management checks were not reliable enough.
Inspectors visited over three days, starting with an unannounced visit. They spoke with people, relatives, staff and health professionals. They checked care files, staff files, medicines and management records.
People said they were generally happy with the care and felt safe. Medicines were managed properly, health referrals were made when needed, infection control was good and the home had strong end of life care arrangements.
However, risk assessments and care plans were inconsistent. Some records did not give staff enough information about people's preferences, mental health or changing needs. Recruitment checks and quality monitoring were also not always effective. Inspectors found breaches of three legal requirements.
The overall rating and all five question ratings were Requires Improvement. This means some parts of the service were working well, but there was limited assurance that care was consistently safe, effective, caring, responsive and well managed.
People generally felt safe
People and relatives told inspectors they felt safe living in the home. Safeguarding concerns were referred to the appropriate authorities.
“People and their relatives told us they felt safe.” from the report
Medicines were managed safely
Medicines were stored securely, records showed proper administration and inspectors observed a safe medicines round. The home had also acted on the previous inspection's concerns about covert medicines.
“At this inspection, we found the provider had acted upon our recommendations.” from the report
Health care support
The home made appropriate referrals to outside health services and included health professionals' advice in care records. A GP visited weekly.
“There was evidence of appropriate referrals to external healthcare services.” from the report
Mental capacity decisions
When people could not make particular decisions, records showed that best interest decisions involved relevant professionals and family members.
“Where it was assessed that people did not have capacity, there was evidence that decisions were taken in their best interests” from the report
Infection control
Staff used protective equipment, cleaning took place throughout the inspection and waste was disposed of appropriately. The home had no concerns at this inspection about previously unlabelled opened food.
“The provider followed good infection control practices.” from the report
Recruitment checks
seriousApplication forms, references and employment histories were not always complete or properly checked. Interview notes were missing from two of the three staff files reviewed.
“The provider did not always follow appropriate procedures when recruiting staff.” from the report
Inconsistent risk records
seriousSome risk assessments and care plans did not match or were not fully completed. Falls information was also recorded differently on paper and electronically, making monitoring less reliable.
“There was still some inconsistency in the way risk was assessed and managed.” from the report
Care was not always attentive
seriousInspectors saw a person left waiting for help after becoming incontinent. They also saw a person's breakfast left to go cold and heard a response that confused someone about their lunch.
“The inspection team intervened and had to approach three staff members who were at the main desk to help this person.” from the report
Care plans lacked personal detail
seriousCare records did not always explain people's interests, routines, history or emotional support needs. Some records were blank, vague or out of date.
“Care plans contained very little in the way of person-centred information” from the report
Weak quality monitoring
seriousAudits and external reports did not reliably identify problems. Falls analysis still contained errors, including falls involving fractures.
“The reports were not effective in identifying some of the concerns we identified during the inspection” from the report
New staff training records
needs fixingNew staff induction was recorded as covering many Care Certificate standards in one day, but inspectors could not see enough evidence of the learning. They recommended that the provider review this.
“It was difficult to know how the required level of training required for the Care Certificate could be delivered effectively over one day.” from the report
- 01How have you checked every resident's risk assessment and care plan for mismatches or missing information?
- 02What evidence can you show that references, employment histories and interview records are now fully checked for every new staff member?
- 03How do you make sure falls are recorded consistently and included correctly in your analysis?
- 04What has changed to ensure people who are distressed or need personal care are helped without delay?
- 05How are you recording each person's preferences, life history, daily routine and emotional support needs?
This was a planned inspection of the whole service, covering all five CQC questions and both the care and accommodation provided. This explanation was written from the published report of 11 June 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 Trinity Court Nursing Home
5 rated inspections over 5 years: the service has held its Good rating throughout.
- February 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017Goodstayed GoodResponsive: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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