CQC report explained · a residential care home
What the CQC found at Trinity House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Staff understood safeguarding, risk assessments were reviewed, staffing was sufficient, and medicines were managed safely.
- Effective?
- Good
- Staff had completed relevant mandatory and specialist training and received supervision. People were supported with health care, legal rights, healthy food and nutrition.
- Caring?
- Good
- Staff were observed to be warm, friendly, polite and caring. They knew people's preferences, histories and signs of anxiety, while promoting independence and respecting culture and beliefs.
- Responsive?
- Good
- Care plans were detailed, person-centred and regularly updated. People had access to social and recovery-based activities, and there was a complaints procedure.
- Well-led?
- Good
- People and staff spoke positively about the management. Audits, meetings, surveys and other checks were used to monitor care and the home.
What inspectors found, February 2019
Rated Good; inspectors found safe, kind, person-centred care, and said a previous medicines shortfall had been addressed.
This was an unannounced comprehensive inspection on 8 January 2019. Inspectors spoke with people living at the home, the manager and support staff. They observed care and checked care records, medicines records, staff files, training records, audits and complaints information.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe and were happy with their care. Staff knew people's needs, preferences and personal histories, and supported their independence, health, activities and contact with others.
At the previous inspection in December 2017, the home had breached a legal requirement because guidance for 'as and when needed' medicines was not safe enough. Inspectors found this had been corrected by this inspection.
Safe medicines management
Inspectors found that medicines were given safely, records were complete and staff were trained and checked for competence. The previous shortfall in guidance for 'when required' medicines had been addressed.
“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
Person-centred care
Care plans covered personal, physical, social and emotional needs. Staff understood changes in people's mental health and responded to updated needs.
“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
Kind and respectful staff
People said staff were kind and caring. Inspectors saw staff treating people politely, respecting privacy and supporting individual preferences and independence.
“We observed staff communication with the residents was warm and friendly, showing caring attitudes.” from the report
Strong management checks
The home had regular audits and spot checks covering areas such as care records, medicines, cleanliness and safety. People, relatives and staff were also asked for their views.
“There were effective systems in place to monitor all aspects of the care people received.” from the report
Activities and rehabilitation
Since the previous inspection, an activities coordinator had been recruited. Inspectors found a range of outings and activities aimed at recovery and greater independence.
“Since our last inspection the service had recruited an activities coordinator” from the report
Inspectors raised no specific concerns in this report.
- 01How do you make sure 'when required' medicines are given only when needed and recorded correctly?
- 02What recovery-based activities are available now, and how do you match them to each person's interests and goals?
- 03How would you respond if my relative's mental health began to deteriorate?
- 04How will my relative be involved in writing and reviewing their care plan?
- 05How do you check that staffing levels remain sufficient when people's needs change?
This was an unannounced comprehensive inspection covering the premises and care provided, with all five CQC question areas rated. 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
Rated Requires Improvement; inspectors found kind and responsive care, but medicines records and quality checks were not fully safe.
This was an unannounced comprehensive inspection on 1 and 6 December 2017. Inspectors spoke with people living in the home, the registered manager and support staff. They observed care and checked care records, staff files, medicines records, audits, complaints and other documents.
The home had improved since the previous inspection. Recruitment checks were safer, the building had been cleaned and redecorated, staff had more training and supervision, and management monitoring systems had been introduced. People told inspectors they felt safe and were happy with their care.
The main remaining problem was medicines. Protocols for medicines given only when needed were not in place, and some staff had not completed medicine competency assessments. The audits had not found this problem, so the home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. Effective, Caring and Responsive were rated Good.
Kind and respectful care
People said staff were caring and respectful. Inspectors observed staff responding to people's moods and needs in a polite and caring way.
“Staff were caring and treated people with dignity and respect.” from the report
Staff understood people
Staff knew people's histories, preferences, routines and signs of anxiety or deteriorating mental health.
“Staff working at the home demonstrated a good knowledge of people's care needs, significant people and events in their lives, and their daily routines and preferences.” from the report
Improved recruitment
The home introduced a recruitment pack and completed checks such as references, identity, right to work and DBS checks before staff started.
“We looked at staff records and saw that there was a safe and robust recruitment process in place.” from the report
Person-centred support
Care plans were detailed and reviewed with people. Staff supported people to make choices, remain independent and take part in community activities.
“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 home environment
The home had been redecorated and repaired. Inspectors found it clean, with infection control measures and cleaning supplies in place.
“At this inspection we found the environment had been improved and had been redecorated throughout.” from the report
Quality checks missed the problem
needs fixingThe new audits covered medicines management but did not identify the missing PRN protocols. This was part of the reason Well-led was rated Requires Improvement.
“However, the audits failed to pick up the shortfall with medicines management in relation to PRN protocols.” from the report
- 01What PRN medicines are currently prescribed, and where are the instructions explaining when and how each one should be given?
- 02How do you check that every staff member who gives medicines has passed a competency assessment?
- 03How do your medicines audits now identify missing records or protocols?
- 04What action was taken after the Regulation 12 breach, and has CQC checked that it was completed?
- 05How are people's views and relatives' views used to check whether the improvements have lasted?
This was an unannounced comprehensive inspection covering all five CQC questions, following a comprehensive inspection on 23 June 2017 that found six breaches. 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
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.
- February 2011
Registered with the Care Quality Commission on 24 February 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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 83 can care for a couple. 12 years' experience on average.
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