Updated 27 January 2025
Date of Assessment: 5 February to 20 February 2025. Trafalgar Care Home is a home providing accommodation and personal care to older people and people living with Dementia. This inspection was promoted due to concerns about the service. The provider was in breach of the legal regulation relating to good governance, premises and providing personal care. Governance systems were not always robust which meant the service was unable to support continued learning to provide consistent good quality care. The home did not always demonstrate a good learning culture. Learning from lessons when things went wrong had not always been embedded, this had placed people at risk of harm. Staff told us they were a dedicated hardworking team, however, did not always feel supported to do their jobs well and this had impacted on their ability to consistently deliver good quality care. The environment was not always safe and well maintained. The home was not always clean and free from the risk of infection. Risks to people were not always understood and managed. Systems to ensure medicines were managed safely were not always robust. Assessments had been completed before people moved into the home and formed the basis of care plans which were regularly reviewed by staff. However, people and their relatives told us were not always involved in the reviews of their care. Staff knew how to speak up, however, told us they did not always feel listened to and did not always feel there was a no blame culture. Staff mostly knew how to safeguard people from abuse. Staff had been recruited safely into the service and received appropriate training for their role. People’s consent to care had been sought and where the person lacked capacity to make decisions, staff had involved those closest to them to make decisions in their best interest. People always had enough to eat and drink to stay healthy. We have asked the provider for an action plan in response to the concerns found at this assessment.