Trinity Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first inspection for this newly registered service. This key question has been rated as good. This meant people were safe and protected from avoidable harm. Risks to people’s health were mitigated and there were enough suitably skilled staff to support people. Staff understood their role in keeping people safe.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they were informed if their family member was involved in an accident or incident. One relative told us, “[Name] has had a few falls, but they are on it straight away.” Another relative commented, “Trinity Manor phone us promptly if anything happens and they are always looking after [Name’s] best interests.” Relatives told us learning had been taken from issues they had raised, and improvements were being made. Typical comments were, “I was concerned with some matters at the home at first, but things have definitely improved” and “I do notice that things are beginning to get better now.”

Staff described a culture of learning under the new manager to improve standards. One staff member said, “They [senior staff] do look at lessons learned, they are open and definitely the manager wants to know about incidents.” A senior staff member told us how lessons had been learned following concerns they found when checking people's care. The staff member said, “We did supervisions and let the manager know.” One staff member who led on reducing falls in the home explained, “With the falls, I meet with the nurses and the seniors and discuss the falls, how many falls we have had and then discuss how to prevent them.” This staff member went on to say, "The manager shares learning, and we share that with the staff as well. Staff need to know what has happened and what is going to happen. We involve them and provide the information they need." The manager understood their responsibility under duty of candour to be open and honest and keep people and their relatives informed of actions taken following any incidents.

The provider had a process for recording and managing accidents and incidents that occurred within the home. Whilst the manager reviewed accidents and incidents to identify patterns or trends at service level, it was not always clear what action had been taken or improvements implemented. A new electronic system for the management of accidents and incidents was being introduced to provide increased management oversight and ensure accountability for any mitigating actions identified.

We received mixed feedback about people’s transition to Trinity Manor. One relative told us about a lack of co-ordination when their family member moved from hospital to the home because equipment they needed, was not immediately available to them. Another person told us, “Not all my medical notes and records came with me from the hospital and that has caused a few problems for me physically and mentally.” However, another person was confident their appointments with external healthcare professionals were managed well.

The manager was open and transparent that when they initially opened the ‘discharge to assess’ (D2A) beds, people’s transition from hospital into the home had not always been managed well. They explained how they had worked with partner agencies to ensure safe and improved pathways and transitions. This included limiting the number of discharges into the home to 3 a week and ensuring they had 72 hours’ notice prior to discharge. The manager told us, “We talked to social workers and assessors to make sure there was a good process so it is safe for the home, and we can support the ICB (Integrated Care Board).” One staff member explained how better management had improved people’s experience. Other staff told us they were kept up to date with changes required to people’s care through handover meetings when people were discharged back to the home from hospital.

Healthcare professionals described the initial admission of people on a discharge to assess (D2A) pathway as not being managed well. Comments included: “This is a care home that suddenly went to being inundated” and “When the D2A residents were flooding in, it seemed chaotic.” However, they told us processes had been developed to ensure the pathway and transition from hospital to the home was managed safely and ensured positive outcomes for people. One healthcare professional described the process as “definitely improving” and another told us, “I have no issues with Trinity Manor regarding D2A beds.”

The provider had a hospital admission and discharge policy. This policy outlined the information which needed to be sent with people should they have an emergency admission to hospital. However, procedure and practice needed to be further developed to ensure there was a consistent and informed approach to information sharing when people needed prompt support owing to health emergencies.

People and their relatives, felt and considered they and others, were safe living at Trinity Manor. Comments from people included: “I feel very safe”, “I do feel safe living here” and “I haven’t been unsafe yet, there have been no major incidents.” When we asked one person what made them feel safe, they responded, “I have my call bell. You can press the button if you are really in trouble, red or orange. If you press red the medics and the whole lot come running and if you press orange the carers come and that gives me confidence.” A relative told us their family member was, “Safe, absolutely and without reservation.”

Staff gave examples showing how they would identify if people were being abused and knew how this should be escalated. One staff member told us, “I would report it to seniors, the home manager or nurses.” We asked the staff member what they would do if there was no action taken to protect people. The staff member said, “I would use the whistle blowing policy.” Staff also understood they could contact the provider and other external agencies if they had any further concerns. The manager understood their responsibility to report any safeguarding concerns to the local safeguarding authority and us, CQC.

People appeared comfortable with staff, and staff supported people without restriction.

Staff were supported to understand their responsibilities to safeguard people through the provider’s safeguarding policy and training. Accessible information reminded staff of their safeguarding responsibilities and included details of the local safeguarding team telephone number. Processes to support the oversight of safeguarding issues were in place, but not consistently followed. The provider had identified this as an area for improvement.

Overall, people and their relatives were confident risks to people’s health and wellbeing were mitigated and managed well. One relative told us, “The hoisting is done very well, it is always done properly, always by 2 people, which is what [Name] wanted.” However, 1 person with diabetes felt staff had struggled to fully understand their diabetes and a relative told us staff had not always followed healthcare professional advice when repositioning their family member to prevent skin damage. The relative explained staff now had accessible information to help ensure it was done safely.

Staff knew about people's individual needs for support and gave examples of how they worked with people on an individual basis to manage their risks. This included ensuring people's bedrooms were free from trip hazards and people were supported to have the equipment to hand they needed to mobilise safely. The manager told us how they helped people to understand any risks to their health and worked with them to develop plans to mitigate those risks. For example, 1 person had expressed a wish not to have bed rails; a compromise had been reached which kept the person safe and respected their wishes. Staff told us any changes or escalation in people’s risks were shared with them during the handover between shifts and at daily meetings. Senior staff explained how they regularly reviewed people’s daily charts to ensure risk management strategies were being implemented and followed by the staff team.

People who required equipment to mitigate risks to their health and wellbeing, had that equipment in place. For example, people at risk of falls from bed had their bed on the lowest setting and crash mats by the side of their bed. Mobile motion sensors were placed in the most appropriate area of a room to alert staff when people with a high risk of falling mobilised without assistance.

Risks to people's individual health and wellbeing were assessed and action taken to minimise those risks. Where risks were identified, people's care plans described the actions staff should take to minimise them. For example, in relation to moving and transferring, epilepsy, nutrition and skin care. Where people had sustained wounds or skin damage, records were maintained of the actions taken to reduce the risk of deterioration and promote healing. However, there were some inconsistencies across care records in relation to managing risk for 1 person who had previously required their drinks to be thickened because of their risk of choking. Staff gave us assurances this would be addressed without delay.

People and their relatives were positive about the adaptation and design of the premises and the equipment available. Comments included, “I do like my room, the view is good, and I like the en-suite facility”, “The rooms and environment are all good, there is plenty of space and they have the right equipment” and “The wheelchair they gave me is good, the seat is very comfortable.”

Staff told us maintenance to the environment was regularly undertaken, with issues reported to the maintenance team being promptly addressed. Staff with delegated responsibilities understood their role in the safe management of equipment and premises.

Trinity Manor was purpose built and provided people with different options of where they wanted to spend their time. There were a variety of communal areas to encourage socialisation and quieter lounges where people could relax or spend private time with their visitors. Bedrooms, corridors and communal bathrooms had enough space to enable staff to manoeuvre equipment safely. The home appeared as well ordered and well presented.

Records demonstrated maintenance and safety checks of the environment and equipment had been completed. Processes ensured any maintenance required was recorded and actioned. Effective systems kept people safe in an emergency. These included regular fire alarm testing and fire equipment checks.

People told us there had been times when there were not enough staff, particularly at weekends. Comments included: “It can vary. In the week it is probably okay, sometimes at weekends it is not adequate. Last Saturday they were clearly very short and there were high levels of staff sickness” and “I think they could do with more staff. There seem to be less at weekends, and we often had to stand at the door and wait to be let in, but we have the codes now.” However, there were indications of more recent improvements and staff being more identifiable by wearing specific uniforms and name badges. One person told us, “They used to go to an agency but now there are more permanent staff. Mostly they are well chosen and most joined within the last month.” A relative commented, “I think there are always enough and now they are in uniform, so you know who they are and what their role is.”

Staff told us there were enough staff to care for people and they were confident additional staff would be recruited as the number of people in the home increased. One staff member said, “The ones they are taking on now are the right staff and they want to learn. I feel there is enough.” Another staff member commented, "At present we don’t use agency staff anymore. There is a consistency with the staff members working here and the residents are used to our own staff rather than the agency.” Staff told us they had received training relevant to their roles. For example, care staff told us they had received training to support their understanding of people’s key needs, such as catheter training. One staff member said after training their practice was observed by the trainer to ensure they were competent in this area. A senior staff member told us new staff were supported by a buddy when they first came to work at the home. Staff said they were not allowed to care for people until their DBS had been checked and references received.

Staff were visible and available in the home. Staff did not appear rushed, and people did not have to wait long if they wanted assistance from staff. Staff communicated with each other to ensure people who needed 2 staff for care tasks received that level of support.

People’s support needs were assessed and regularly reviewed to enable the provider to identify the number of staff required to deliver safe and effective care. Rotas demonstrated identified staffing levels had been maintained. The provider’s recruitment policy ensured staff were recruited safely. New staff received an induction, and training was available for staff to develop their skills and acquire knowledge to underpin their roles and future development. The provider was building the number of bank staff who could pick up shifts at short notice to improve continuity and consistency within the staff team.

People and their relatives were generally positive about infection control practices. However, some relatives felt standards of cleanliness were not consistently maintained in communal kitchen areas. One relative told us, “The communal kitchen is usually full of old unwashed cups and mugs. It feels in this respect that the home is still finding their feet and things are still a bit disjointed.”

Staff told us they had received training in infection control and gave examples of how they put their training into practice. For example, by using appropriate bags for contaminated linen, using personal protective equipment (PPE) and frequent handwashing. Staff advised there was sufficient PPE to promote good infection prevention. Staff with responsibilities for housekeeping had a good understanding of the actions required to reduce the likelihood of the spread of infections. Staff told us they attended daily meetings with the whole staff team, so any actions required to support infection prevention would be identified.

All areas of the home were clean and smelt fresh. The home was well stocked with equipment to support good infection control practices such as PPE and hand sanitiser. There was a chute to transfer soiled items from care floors to the housekeeping area which helped to minimise the risk of the spread of infection.

Staff were supported to understand how to prevent and manage infectious outbreaks through information and policy displayed in staff areas within the home and training. Guidance on the correct use of PPE was also displayed, along with the provider’s vaccination refusal policy. Care plans reminded staff of good infection control practices when delivering care. Systems ensured the flow of items through the laundry area promoted good infection control.

People’s comments on the availability, administration and application of medicines were positive. One relative told us their family member was prescribed a number of different medicines and commented, “The nurses are good and know their job and there have been no problems.” One relative told us how changes to their family member’s medicines had a positive outcome for them. They explained, “They sorted out [Name’s] painkillers. The changed pain relief worked and although they couldn’t see or hear well, they could engage and talk.” We saw staff were mindful of when people required their medicines at specific times and responded to this. For example, staff had set an alarm to ensure 1 person received their Parkinson's medication at the time prescribed. We also saw staff kept medication keys secured.

Staff told us medicines were administered by nurses and senior staff. Senior staff told us they were not allowed to administer people's medicines until they had received training, and their competency had been checked. Staff understood how medicines should be stored and kept secure. Staff told us they followed NICE guidelines when managing and administering controlled drugs. For example, two staff were required to check in and administer such items. Staff gave examples showing how people’s medicines were regularly reviewed by their GPs and their care plans and protocols for the administration of ‘as required’ medicines changed accordingly. A senior staff member told us they reviewed the medicines administered to people each day. In addition, the staff member said where people were prescribed blood thinners, “We make sure staff understand the implications of this by putting it in their care plans.”

Overall, medicines were managed, stored and administered safely, in accordance with best practice guidance. However, we found improvements were needed in the management of medicines administered via a patch applied to the skin. Records did not always evidence these had been managed as per the manufacturer's instructions. For example, 1 person had a patch medicine that was not to be applied to the same area for 14 days. Records did not record where the patch had been applied. A healthcare professional told us how the recent implementation of an electronic medicines system had improved medicines management. They told us the system ensured people had their medicines when they needed them and any amendments to people’s prescriptions were quickly actioned.