CQC report explained · a residential care home
What the CQC found at Trinity House Annexe
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risk assessments covered mental and physical health risks, medicines were checked, and there were enough staff to meet people's needs.
- Effective?
- Good
- Staff had completed relevant mandatory and specialist training and received supervision. People had access to health services and were supported to eat healthily.
- Caring?
- Good
- People described staff as kind and caring. Inspectors saw respectful, warm interactions, and staff understood people's histories, preferences, moods and cultural needs.
- Responsive?
- Good
- Care plans were detailed, personalised and regularly updated. People were supported with activities, health appointments, independence and contact with family.
- Well-led?
- Good
- People and staff spoke positively about the management. Audits and other checks covered care records, medicines, cleanliness, safety and the condition of the building.
What inspectors found, February 2019
Trinity House Annexe is rated Good; inspectors found safe, kind and personalised care, and said a previous medicines breach had been addressed.
This was an unannounced, comprehensive inspection on 8 January 2019. Inspectors spoke with all five people living at the home, the manager, the deputy manager and four support workers. They observed care and checked care records, medicines records, staff files, training records, rosters, audits and complaints information.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines management, detailed care plans, respectful support and good links with health services.
A previous inspection in December 2017 found a legal breach because safe instructions were not in place for medicines given when needed. Inspectors said this had been corrected by this inspection.
Safe medicines
Medicines records were complete and stock checks matched the records. Staff had training and competency checks, including for medicines given when needed.
“Staff followed the guidance which was now in in place on managing PRN 'when required' medicines for each person and documented the reasons why they had administered the medicines.” from the report
Kind and respectful staff
People said staff were kind and caring. Inspectors saw staff communicate warmly and respectfully, while promoting people's independence.
“People told us staff were kind and caring and we observed this to be the case.” from the report
Personalised support
Care plans covered personal, physical, social and emotional needs. Staff knew people's backgrounds, preferences and signs that their mental health might be worsening.
“Care plans were detailed, person centred, and provided good guidance to staff about how people's care and support needs should be met.” from the report
Activities and independence
People took part in recovery-focused activities, both in the home and outside it. The home also supported people to develop skills and move towards more independent living.
“We found that there was a good range of recovery based activities on offer.” from the report
Strong oversight
The management team used regular audits, spot checks, meetings and surveys to monitor the service. Staff said they felt supported and valued.
“There were effective systems in place to monitor all aspects of the care people received.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you identify and respond if my relative's mental health starts to deteriorate?
- 02How do you record and review medicines given when needed, and how do you check that the previous medicines problem does not happen again?
- 03What recovery-focused activities would be available for my relative, both inside and outside the home?
- 04How would you support my relative to maintain contact with family and develop greater independence?
- 05How are care plans reviewed when there is an incident or a change in someone's needs?
This was an unannounced comprehensive inspection covering the overall service, including accommodation and care, and all five CQC rating areas. This explanation was written from the published report of 8 February 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.
What inspectors found, January 2018
Trinity House Annexe was rated Requires Improvement; inspectors found caring and responsive support, but medicines and quality checks were not fully safe.
This was an unannounced comprehensive inspection on 1 and 6 December 2017. Inspectors spoke with six people, the manager and four support workers. They observed care and checked care records, staff files, medicines records, training records, audits and complaints information.
The home had made major improvements since the previous inspection in June 2017. Recruitment checks were safer, the building was cleaner and better maintained, and staff had more training and supervision. People told inspectors they were happy, felt safe, and were treated with dignity and respect.
There was still a legal breach about medicines. The home did not have clear protocols for medicines given only when needed. Its quality checks had not found this problem. The overall rating was Requires Improvement, with Safe and Well-led also rated Requires Improvement. Effective, Caring and Responsive were rated Good.
Respectful care
People said staff listened to them, respected their dignity and gave them choices. Inspectors also observed polite and caring interactions.
“People told us they were happy with the care and support they received.” from the report
Good care planning
Care plans were detailed, personal to each person and reviewed regularly. They gave staff clear guidance about people's needs and preferences.
“Care plans were detailed, person centred, and provided good guidance to staff about how people's care and support needs should be met.” from the report
Improved recruitment and staff support
The home had introduced stronger recruitment checks. Staff were receiving regular supervision and training, although some training records were inaccurate.
“The home was clean and well maintained, staff were receiving regular supervision and training and staff recruitment procedures were now safe.” from the report
Improved premises and cleanliness
The home had been redecorated and several repairs had been completed. Inspectors found the home visibly clean, with food stored safely.
“At this inspection we found the environment had been improved and had been redecorated throughout.” from the report
Medicine records
seriousRecords did not clearly show when some long-acting mental health medicines had been given or when the next dose was due. Inspectors said this could create a risk of medicine errors, especially if records were transferred to another care setting.
“We noted on MAR chats that it was not clear what date people were given these specific medicines and when it was next due.” from the report
Quality checks missed the medicines problem
needs fixingThe home had introduced audits, but they did not identify the missing PRN protocols. This is why the Well-led rating remained Requires Improvement.
“However, the audits failed to pick up the shortfall with medicines management in relation to PRN protocols.” from the report
- 01What clear protocols are now in place for each person's medicines that are given only when needed?
- 02How do you now record the date and next due date for long-acting mental health medicines?
- 03How do you check that medicines records are complete and accurate?
- 04How do your audits now make sure that medicines shortfalls are identified and corrected?
- 05Have all staff who administer medicines completed their competency assessments?
This was an unannounced comprehensive inspection covering the premises and care provided, with ratings given for all five key questions. This explanation was written from the published report of 27 January 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 Trinity House Annexe
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- February 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 10 October 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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Most charge £980 to £1,300 a week. 83 can care for a couple. 12 years' experience on average.
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