8 February 2019
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
The inspection team consisted of one inspector, a specialist mental health advisor and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Before our inspection, we reviewed the information we held about the home which included statutory notifications and safeguarding alerts.
We spoke with five people who used the service. We also spoke with the registered manager, the deputy manager and four support staff.
During our inspection we observed how staff supported and interacted with people who used the service.
We also looked at a range of records, including; six people’s care records, staff duty rosters, four staff files, arrange of audits, the complaints log, minutes of various meetings, staff training records and Medicine Administration Records (MARs) for all the people using the service.
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 Annex 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 Annex is registered to provide care and support for up to five people with mental health needs. Trinity House Annex works jointly with a neighbouring care home,Trinity House, 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 five 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 at the centre of their practice. Care plans focused on the whole person, and assessments and plans were regularly updated.
The service was well led. There was a clear set of values in place which all the staff put into practice. The management team had developed quality assurance checks, to make sure standards of care were maintained. There was an open culture and staff said they felt well motivated and valued by the registered manager.