Trimarge Care and Clean Ltd

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.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained the same.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to Good Governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had vision and strategy, but the delivery of care and lack of accurate records was not aligned with the vision and culture of the service.

The service’s vision included being a person-centred provider with compassionate care at the core of the services. This was monitored through audits and regular feedback from people, relatives and staff. Spot checks were also carried out to ensure people received safe personalised care. However, during our assessment we found that systems would need to be made more robust especially around risk assessments and medicine management to ensure the delivery of care aligned with the services vision.

Leaders did not always have the skills, knowledge and experience to lead effectively.

The nominated individual knew people well and was committed in ensuring people received safe and effective care. This was done through seeking feedback from people, relatives and staff. Spot checks were also carried out to ensure staff delivered high quality care. A relative told us, “They [management are great].”

However, some shortfalls remained since the last inspection with medicine management, record keeping and good governance in addition to shortfalls with risk assessments that was identified as part of this assessment, which would require addressing to ensure people always receive safe care and support.

A registered manager was not in place, but we were informed that the care manager was in the process of submitting the registration with the CQC.

Staff meetings were held regularly by the management team. The agenda included discussion on training, medicine, and infection control.

Staff were positive about the nominated individual. A staff member told us, “[Nominated individual] is good, there is no issues. [Nominated individual] listen and is proactive.” Another staff member commented, “Management always listens to us when we have problems. [Nominated individual] is good and want the best for us.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a whistleblowing policy that included details on how to raise concerns both internally and externally, which allowed staff freedom to speak up.

Staff knew how to use the whistleblowing policy and understood their role and responsibilities of reporting concerns and knew who to go to if they needed to. A staff member told us, “Whistleblowing is reporting any form of behaviour that is not right, it could be internal. Can report to manager, local authority and CQC.”

The provider valued diversity in their workforce. Staff had been trained in equality and diversity and an equality and diversity policy was in place. Systems were in place for flexible working arrangements as shift plans showed staff were able to work flexibly. Systems were in place to record incidents towards staff. Staff did not have any concerns about a lack of support and were very positive about the service and the management team valuing diversity.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

During our last comprehensive inspection, we found good governance systems were not in place to ensure people received safe and effective care due to shortfalls with medicine management and staff recruitment. At this inspection, we found there was not an effective quality assurance system in place to identify shortfalls and act on them to ensure people were safe.

Audits were carried out on care plans, medicines, supervisions and infection control. While some of the audits in the areas of supervisions and infection control were compliant, the audits on care plans and medicine management required strengthening. The audits did not identify the shortfall we found in the area of risk assessment to ensure people received safe and effective care at all times.

The lack of not having robust quality assurance processes and not keeping an accurate, complete and contemporaneous record of people who use the service, may impact on people’s care and support if staff are not able to support people safely and meet their needs.

Quality monitoring systems were in place, which included getting feedback from people, relatives and staff through surveys, spot checks and supervisions. The feedback was analysed and action taken.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We did not receive any concerns from partners about the service. A social professional told us, ‘Trimarge consistently demonstrated a strong commitment to service delivery, responding swiftly to urgent needs and going above and beyond to support the individuals in our care.’

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Robust systems were not in place for learning and improvement. Some improvements had been made since our last inspection with staff recruitment checks. However, further improvements were required with medicine management, which was a concern at our last inspection. In addition, improvements were required with risk assessments.