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Inspection Summary

Overall summary & rating


Updated 8 February 2019

This comprehensive inspection took place on 8 January 2019 and was unannounced.

We carried out an unannounced comprehensive inspection of this service on 1 December 2017 where one breach of legal requirement was found. The provider failed to have safe medicines protocols in place for medicines that were to be given “as and when needed.”. At this inspection we found the provider had addressed this breach.

Trinity House is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Trinity House is registered to provide care and support for up to five people with mental health needs. Trinity House works jointly with a neighbouring care home, Trinity House Annex, run by the same provider. The building is a detached house in a residential street in Hendon and is well served with local transport, shops and parks. There are four bedrooms on the first floor and one on the ground floor. Three rooms have an en-suite facility consisting of a shower, toilet and there are washbasins in each room. The staffing structure consists of the registered manager, deputy manager and support workers, providing 24-hour support. The stated aims of the home are, 'To promote independence, self-determination and to contribute to the rehabilitative process. This enables service users to attain their optimum quality of life, and to move on to more independent living, in a home of their own'.

There were four people using the service at the time of our inspection.

There is a long standing registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they were very happy with the care and support they received.

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.

Staff told us they enjoyed working in the home and spoke positively about the culture and management of the service. Staff described management as supportive. Staff confirmed they were able to raise issues and make suggestions about the way the service was provided.

The manager and deputy manager provided good leadership and people using the service and staff told us they promoted high standards of care.

The service was safe and there were appropriate safeguards in place to help protect the people who lived there. People were able to make choices about the way in which they were supported and staff listened to them and knew their needs well. Staff had the training and support they needed. There was evidence that staff and managers at the home had been involved in reviewing and monitoring the quality of the service to drive improvement.

Recruitment practices were safe and relevant checks had been completed before staff worked at the home. People’s medicines were managed appropriately so they received them safely

There were sufficient numbers of suitably qualified, skilled and experienced staff to care for the number of people with complex needs in the home.

Staff were caring and always ensured they treated people with dignity and respect.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. People’s views on the service were regularly sought and acted on.

People participated in a range of different social activities and were supported to attend health appointments. People were supported to maintain a healthy balanced diet.

Person centred care was fundamental to the service and staff made sure people were

Inspection areas



Updated 8 February 2019

The service was safe.

Staff understood the provider�s safeguarding procedures and could explain how they would protect people if they had any concerns.

The service ensured the proper and safe use of medicines, and protected people by the prevention and control of infection

Sufficient numbers of suitably qualified staff were deployed to keep people safe.



Updated 8 February 2019

The service was effective.

People received care from staff that were trained to meet their individual needs. Staff felt supported and received on-going training and regular management supervision.

People received the support they needed to maintain good health and wellbeing.

People were supported to eat healthily.

The manager and staff had a good understanding of meeting people�s legal rights and the correct processes were being followed regarding the Deprivation of Liberty Safeguards.



Updated 8 February 2019

The service was caring.

People told us staff were kind and caring and we observed this to be the case. Staff knew people�s preferences and acted on these.

People told us they felt involved in the care planning and delivery and they felt able to raise any issues with staff or the registered manager.

Staff knew people�s background, interests and personal preferences well.



Updated 8 February 2019

The service was responsive.

People�s needs were assessed. Staff responded to changes in people�s needs. Care plans were up to date and reflected the care and support given. Regular reviews were held to ensure plans were up to date.

Care was planned and delivered to meet the individual needs of people.

There was a complaints procedure in place.



Updated 8 February 2019

The service was well led.

People and staff spoke highly of the registered manager; they found them to be dedicated, approachable and supportive.

People living at the home, and staff were supported to contribute their views.

There were systems in place to monitor the quality of the service