Trinity House

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 assessment for this service. This key question has been rated Good: This meant people were safe and protected from avoidable harm.

This service scored 69 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents were managed and monitored effectively. We viewed incident forms which had been completed by staff and contained details of the incident and the support provided. One staff member said, “I complete incident reports when required with details of the incident. We also have regular team meetings and staff debriefs if there are any incidents, which we go through together and discuss any learning required.”

There were systems in place to monitor and learn from incidents. The registered manager monitored incidents monthly to ensure action had been taken when required and to note any trends or themes emerging. The registered manager ensured lessons were learned when feedback from other professionals highlighted areas for improvement. The registered manager said, “I or we always take on board any feedback received, and we are learning from this to improve the support provided to people.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People and their relatives told us staff raised concerns with health and social care professionals when required. One relative told us staff contacted the relevant health professionals whenever they had concerns. They said, “I don’t have to ask, the staff just contact them when they’re concerned.” Staff confirmed they sought and followed advice from external professionals to ensure they were providing support which met people’s changing needs.

People’s care records contained details of advice received from health and social care professionals, and care records were updated to ensure staff had up to date information to follow when providing care. One staff member said, “Any advice received from professionals is updated in the care plans and risk assessments. The records are always updated as we learn something new about people or things change.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe, and relatives were assured their loved ones received safe care. One person said, “I feel safe knowing I can talk to staff or the manager when I have any concerns and because they listen to me.” A relative said, “I know [person’s name] is safe as they are happier here [Trinity House] than anywhere else they have lived.”

Staff understood their responsibilities when safeguarding people from abuse and explained how they would report any concerns raised. One staff member said, “I have weekly chats with people where I can assess their emotional wellbeing and body maps are used to record concerns like bruising. If a person raised a concern or I saw abuse I would inform the manager and report to safeguarding.”

The registered manager followed the provider’s procedures to report suspected abuse to the Local Authority. They said, “As well as reporting abuse to the Local Authority, it is my responsibility to ensure all staff understand the reporting procedures. I have trained a member of staff in the process to report directly to the safeguarding team in my absence, so people continue to be protected.”

Where people were deprived of their liberty, appropriate Deprivation of Liberty Safeguards (DoLS) authorisations were in place. We reviewed the conditions attached to these authorisations and found they were consistently adhered to, ensuring people remained safe and legally protected.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s risks were assessed and mitigated whilst promoting their independence. Relatives told us they and people living in the home were involved in decisions about managing risks. One relative said, “Staff asked us lots of questions when [person’s name] moved to the home and they have regular meetings with [person’s name]. I know they have listened because [person’s name] is involved in all the things they like to do, but in a safe way.”

Staff understood people’s individual risks and explained how they supported people to remain safe, whilst encouraging people to be as independent as possible. The records we viewed contained personalised information for staff to follow to ensure people were supported safely. One staff member said, “There is lots of information to help us understand people’s risks and how to support them, which are updated regularly. We have weekly meetings with each person to discuss all areas of their support so we can identify any changes needed.”

Positive Behaviour Support (PBS) plans were in place to guide staff when supporting people who displayed distressed behaviours. The PBS plans and care plans were individual to the person and contained details of the possible triggers to the distress and how staff needed to support the person during this time. The care records showed episodes of distressed behaviour were addressed in line with PBS guidance and low-level interventions, such as distraction and diversion, were used before physical or chemical restraint were considered.

Staff understood the importance of supporting people in the least restrictive way. One staff member said, “I support [person’s name] using re-direction, offering emotional support and by keeping [person’s name] distracted through activities and trying to take their mind off things if they are struggling.” Another staff member said, “We have training for restraint, but this is only to be used as a last resort if other methods have not helped such as re-direction or distractions, we would always try other things first.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Relatives told us they had no concerns about the environment. One relative said, “[Person’s name] has their own bedroom, and they help to keep it clean and tidy. Where there have been issues that need fixing, these have been completed.” One person took pleasure in showing the inspector their room and their personalised items within it.

The environment was tidy and free from unnecessary trip and slip hazards. The layout supported people to move around in comfort. Health and safety checks were in place and regularly carried out to ensure potential environmental risks to people were being monitored safely.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider’s recruitment files showed all required pre‑employment checks had been completed, ensuring only suitable staff were employed. However, improvements were needed to the provider’s application forms to ensure a full employment history and previous qualifications were included. Without this information the provider could not fully assess applicants’ suitability, before offering an interview. We fed this back to the registered manager who told us they would update the application forms to include this information.

There were enough staff available to meet people’s needs, which was confirmed by people, relatives and staff. Additional staffing was provided when people were in hospital to ensure they received consistent support from staff who knew them well and could advocate on their behalf. One person said, “There is always someone to take me where I like to go.” A relative said, “There are always enough staff about when I visit, and I know [person’s name] goes out all the time doing things they like to do with staff.” One staff member said, “We work well as a team, and there are enough staff. We cover each other when needed because we all care about the people we support, everyone is supportive.”

Staff told us they had received an induction before they started to provide care including training to carry out their role, which was tailored to people’s individual needs and conditions. Competency checks were carried out to ensure staff understood the training received. One staff member said, “The induction was good. We get refresher training, and training for specific areas such as autism and I have been asked if I am interested in completing an additional Health and Social Care qualification.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was well maintained and clean throughout. Staff used personal protective equipment (PPE) when required to reduce the risk of cross-contamination. Staff told us they used PPE when required and confirmed it was always available to them. One staff member said, “We don’t need to use a lot of PPE for supporting with personal care as its mainly prompting, as we promote people’s independence as much as possible. It’s there for when we need it though.”

The registered manager ensured staff understood how to reduce the risk of cross contamination through training and infection control policy and procedures.

The provider made sure that prescribed medicines and treatments were safe and met people’s needs, capacities and preferences. Some improvements were needed to ensure there was sufficient guidance for staff to support people with unprescribed over the counter (OTC) medicines.

People were supported with their medicines and creams as prescribed. Detailed PRN protocols were in place to provide staff with specific guidance when people required these medicines. PRN is medication required for people as and when needed, such as for pain or to alleviate anxieties. However, improvements were needed to ensure records were available to provide staff with guidance when supporting people with over the counter (OTC) medicines. For example, 1 person used an over-the-counter cream to relieve specific areas of sore skin. Staff we spoke with were aware of why this cream was needed. However, there were no records identifying how often the cream should be used or any possible side effects. We fed this back to the registered manager who stated they would put this in place immediately.

People and relatives confirmed staff understood how and when they needed their medicines and creams. One person said, “The staff are great, they come and tell me when I need my medicine, or I would forget.” One relative said, “I have no concerns with [person’s name] getting their medicines, staff know what they are doing and they manage them well.”

Medicine Administration Records (MARs) were used to record when staff had supported people with their medicines and topical creams. The MARs contained guidance for staff to follow for prescribed medicines. Staff knew people well and were able to explain how they supported people with their medicines and topical creams.

Staff told us they were trained in the administration of medicines, and competency assessments were conducted to ensure medicines were administered safely in practice. One staff member said, “I have had medication training. We all have regular competence checks every 6 months where we are observed administering medication. [Registered manager’s name] sends out reminders and details of changes to all staff. These are then discussed at the monthly staff meetings to make sure we understand them.”