TrinityPlus Healthcare Services improved from Requires Improvement to Good, resolving prior breaches of Regulation 17 relating to recruitment records, medicines administration records, and governance systems. The focused inspection of Safe, Effective and Well-Led found strong leadership, safe staffing, effective medicines management, and good multi-agency working, with only a minor inaccuracy in the training monitoring system noted.
Concerns (1)
minorRecord keeping: “The monitoring of training and supervisions was not always accurate. The monitoring system displayed incorrect dates and some training which had been completed was not recorded.”
Strengths
· Safe recruitment practices with a new system ensuring appropriate DBS checks were conducted and recruitment files were accurate and complete.
· Medicines managed safely via a new electronic management system with live alerts for delayed or missed medication administrations.
· Systems in place to record, analyse and cascade learning from complaints, safeguardings, accidents and incidents.
· Staff supported by a familiar and consistent team; people reported receiving the same carer who knew their routine.
· Registered manager attended Provider learning events across two local authority areas and embraced continuous learning.
Quality-Statement breakdown (15)
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood
TrinityPlus Healthcare Services received an overall rating of Requires Improvement at its first inspection, with three regulatory breaches of Regulation 17 identified relating to recruitment record-keeping, incomplete medication administration records, and the absence of quality assurance systems. The service demonstrated genuine strengths in person-centred caring practice, staff training, infection control, and safeguarding, with Good ratings across Effective, Caring, and Responsive domains.
Concerns (6)
criticalRecord keeping: “Suitable references had not always been retained in staff files. Risk assessments around information held on a DBS check were not in place at the time of our inspection.”
criticalMedication management: “Staff did not always record the reason why they hadn't administered someone's medicines... this information was not recorded robustly on the medicine administration records.”
criticalGovernance: “The provider failed to have systems and processes in place to effectively monitor and improve the quality of the service. The provider was not able to provide us with any evidence of audits.”
moderateIncident learning: “The provider did not have clear systems and processes in place to identify when things went wrong, and then effectively learn lessons.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post. A new manager had been recruited during the inspection process.”
minorCommunication with families: “One person told us 'communication could be improved' and that on occasion they 'had difficulty getting through to the office.'”
Strengths
· Staff treated people with dignity, respect and kindness; people felt safe and comfortable with care workers.
· Risks to people were assessed including environmental and medical condition risks, with appropriate plans in place.
· Staff received appropriate induction and ongoing training, with shadowing of senior staff until confident.
· Continuity of care was prioritised; people were supported by the same staff team where possible.
· Infection prevention and control was managed safely with up-to-date policies, PPE access and training.
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experience
Good
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffRequires improvement