Trinity Manor

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first inspection for this newly registered service. This key question has been rated good. This meant leaders and the culture they created supported the delivery of high-quality, person-centred care. Leaders demonstrated a commitment to listen and learn to drive improvement in the quality-of-care provision. Staff described a supportive management team who were visible and available to them.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they were committed to providing people with the care they wanted. One staff member told us they were encouraged to focus on the needs of the people they cared for and to support new staff, so they were equipped to do this too. The staff member explained, “You share information with new staff, so they feel part of the team. There were open arms when I came here, and I do this too.” Another staff member described how they were managed and said, “Managers want us to work as a team. You can talk about any concerns or issues.” Staff explained how the new manager had impacted on the culture within the home. Comments included: “The home itself has got a lot better with [manager] taking over, she is absolutely brilliant. The mood of the place has got a lot better", "Everyone is starting to work together because the communication has got better" and "[Manager] is doing incredibly, she has really picked this place up and moved it forward. She has been absolutely incredible." The provider’s quality manager explained how the culture in the home had improved resulting in better outcomes for people and improved morale. They told us, “Over the last couple of months I can see the hard work that has gone into making changes, it is taking time to embed but you can see how hard people are working and want to make the home work and improve."

Processes were in place to share the direction and culture of the home. New staff were given a handbook when they started working at Trinity Manor which set out the provider’s vision for the service and their expectations of staff in delivering high standards of care. The provider used a buddy system where new staff were shadowed and supported by a mentor to ensure they understood their role. During their probation new staff were monitored with regular supervision. The culture of support was continued through learning, supervisions, annual appraisals and staff meetings.

Staff found the management team to be visible and available to them. One staff member said, “[Manager] is approachable. We are lucky, because [provider] also comes here, and we can communicate with them too.” Other comments included: “We have a deputy. They are very helpful and listen to us” and “I feel supported. I get supervisions and do them for my staff. I feel we are looked after and would recommend Morar as an employer.” Staff told us communication could sometimes be better, but this was improving. One staff member said, “Communication could be better across all the teams, but we are going in the right direction.” The provider’s quality manager explained their role was to assess quality of care and provide a supportive role within the home. They explained, “I do quality visits to see where I can support, do some training with the team and join some team meetings to see where I can support to drive that improvement." Another member of the management team told us, "It is leading rather than telling. If they see you doing it, you hope by leading by example you bring them along. You have to have conversations and supervisions at times, but it is about working with staff and encouraging them."

The provider was implementing a new management structure with clear roles and delegated responsibilities. Processes were in place to ensure leaders at every level were visible and led by example. For example, there were manager’s ‘walk arounds’ and flash meetings with senior staff every day to discuss any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities. The provider’s operations manager and quality manager were consistent presences in the home and supported the management team through the provider’s quality assurance processes.

Staff were not always able to explain how whistleblowing policies protected them to raise any concerns they had. However, other staff told us they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home. One staff member told us, “If I felt the manager had not done something with my issues, I could go to the regional manager." Some staff felt they had raised concerns about a lack of basics such as drinking glasses, but this had not been actioned promptly. One staff member said, "We don’t have enough glasses. We end up giving residents the coffee mugs. We reported it, they say they have ordered the glasses and the cups, but we are still waiting." Managers acknowledged there had been some issues but assured us the order had been submitted and received into the home. While most staff felt able to escalate concerns above the manager if they needed to, this confidence was not shared by all staff.

The provider had some processes in place to support staff to speak up. This included supervision meetings, handovers, daily flash meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to underpin their understanding of their responsibility to speak up. However, the provider did not have a formal mechanism to support staff who may not feel confident to speak up, such as a Speak-Up Guardian or staff representative. Feedback from some staff indicated this would be of benefit to them. People were given information when they moved to the home about how to raise a concern. However, complaints management was not always robustly recorded.

Staff gave us examples showing how they were supported to work flexibly, when they had parental responsibility. One staff member said, “Managers are flexible regarding shift patterns.” The manager recognised the importance of reasonable adjustments to support inclusion. They explained how they supported people through risk assessments to continue in their role after periods of ill health.

The provider had policies to promote inclusivity, equality and diversity and protect staff from discrimination and harassment. The staff handbook given to all new staff at the start of their employment referenced these policies and provided guidance on their implementation within the home. Where a need was identified, the provider offered reasonable adjustments to support staff to maintain their role and position within the home.

Staff told us there had been changes to the management of the home and they saw the manager often. Staff said they were supported to know what care people required through the information recorded on handheld tablet devices linked to the electronic care planning system. One staff member said, “We find the tablets good because they say what you need to do.” A member of senior staff told us they had responsibility for monitoring staff, to ensure people’s well-being. This included checking people’s care plans were up to date, and medicines were regularly audited. The member of staff also told us about some of the checks the provider undertook, for example, in relation to people’s welfare and call bell response times, so they could be assured people were receiving good care. Senior care staff gave examples of daily checks they did on staff practice. This included in relation to care recording, observations on how people were assisted to eat and to ensure care tasks were completed. The provider’s quality manager explained the progress made in the home because of improved oversight by the new manager. They told us, “[Manager] has much more oversight and is actioning things more effectively. The team are still adjusting to change but I am seeing a difference, and I am hearing from residents and families that things are improving on a day-to-day basis. I can now see that oversight, but it needs a bit more support to embed those practices and processes."

The provider had a process for assessing the quality and safety of the service provided. A recent quality assurance assessment had identified significant areas for improvement and the provider had issued the service with an improvement plan. However, some internal audits and checks were not consistently completed in line with the provider’s expectations, and it was not always clear what action had been taken or changes implemented from findings. Internal processes to quality assure the service needed to be further improved to identify areas for development and to create an action plan to further drive improvement at the service. The provider had recognised this as an area for development and a new manager had been appointed. The provider was also in the process of implementing a new management structure to provide increased leadership and accountability throughout the home. This included the appointment of a new deputy manager and 2 clinical leads to promote good practice, drive improvement and ensure the safety of care provision in all areas. We saw progress being made in relation to the provider’s service improvement plan.

Feedback from people and relatives reflected a service that had been through some challenges and not always attained consistency in the quality-of-care provision. However, people recognised the effectiveness of the new manager and told us recent improvements were attributable to them and their listening style. One relative told us, “It went very well at the beginning, then there were hiccups in between when it was clear that things were sliding. Then the new manager was appointed, and things started improving.” Another relative told us, “The manager is very good and very nice, she seems to deal with things straight away and she never seems hassled. I have faith in the new manager and some of the old (previous) staff have returned and I think their returning is a good sign.” People knew who the manager was and mentioned their availability, open-door policy and willingness to listen to their views. However, 1 relative expressed concern there was no management presence at the weekend.

Staff told us they regularly worked with health professionals and religious groups so people’s needs would be met. A staff member told us, “We work with priests for end-of-life care, physiotherapists and OTs (occupational therapists). Nurses go to the tissue viability nurses for skin advice and treatment plans. We've not had to access the falls team but would consider this alongside the resident’s GP.” The manager stressed the importance of collaborative working with multi-agency healthcare professionals to maximise the effectiveness and benefits of the discharge to assess scheme.

Healthcare professionals who visited Trinity Manor described a management team who had worked over recent months to implement processes to improve communication and the quality of care. One healthcare professional told us, “[Manager] seems to want to try and make it work and I like the way she is respectful about the staff. They have got some great staff, and they really want it to work for them." Other comments included: “The new manager has helped because she has seen and felt it herself and now she is manager, she is able to implement changes very quickly” and “[Manager] is visible and approachable.” Partner agencies described a commitment to learning from advice and guidance to improve standards of clinical care. One partner said, “The new home manager has been very responsive and engaging with us and put the recommended actions into place.” This was supported by a healthcare professional who told us, “There is a good dialogue with staff about where things could be better or improved.”

The provider had systems and processes to ensure people’s needs were reviewed with partners. The provider listened to feedback from partners and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

Staff told us the manager and senior staff were keen to find out if there were any areas they could improve. One staff member said, “[Manager] does find out about any problems, and she is on it straight away.” Another staff member said staff suggestions for improving people’s care were listened to. This staff member said, “We made a suggestion about staff allocations. We suggested splitting each floor across 2 teams. We still help each other but have more opportunities to get to know people." A senior staff member gave an example of managing relatives’ expectations and said external health care professionals had been involved in supporting the person. The staff member told us, “Sometimes families need reassurance. I think to be like an open book is better. You don't hide things; you need to learn from them.” Another staff member told us, “When someone does something wrong, they will do a supervision and then they will supervise that person to see if the person is doing the right thing. I would tell them I had made a mistake so they can give me information about how to do it correctly next time." Staff told us they were encouraged to take further qualifications to improve their practice and ensure their knowledge was up to date.

The provider’s representatives were open and transparent about the challenges the service had faced since it opened 12 months ago. They acknowledged feedback had not always been positive but demonstrated a continuing commitment to listen and learn to drive improvement and improve the quality-of-care provision. This included restructuring the management team, recruiting more permanent staff and building a team of bank staff to cover gaps on the rota. The provider had also appointed champions in the home in areas such as wound care, falls management and infection control. Champions took responsibility for ensuring processes reflected best practice, supporting their colleagues and cascading information when things changed. Processes had been introduced to support improved learning such as managerial walk arounds and daily meetings to immediately address issues as they arose. Comments by people, relatives, staff and external partners demonstrated a trajectory of improvement through learning and the development of more robust processes.