Trafalgar Care Home

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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to clean, secure and suitable premises

This service scored 47 (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 process in place to investigate safety concerns and learn lessons to prevent them from happening again, however, this was not always robust and learning had not always been embedded into the service. At our last inspection we identified that mattresses used to reduce the likelihood of skin breakdown had not always been set to the correct setting placing the person at risk of harm. At this assessment, we found the checks the provider had put in place to prevent this from happening again had failed to identify 2 mattresses that had been set incorrectly. We discussed this with the registered manager who told us they would be implementing further training for staff and change the system to make it robust. We were unable to assess the effectiveness and sustainability of this change during this assessment. The management team told us, they had learned following a recent safeguarding concern into skin integrity. As part of their learning, they instigated a weekly “Tissue Tuesday” whereby a healthcare professional reviewed people who required skin care, and upskilled a senior as a “Tissue Champion” who focused on ensuring appropriate checks of people’s skin was in place to identify any concerns early and reduce the likelihood of skin deterioration. The local safeguarding team were satisfied with these actions.

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. For example, when a person was admitted to hospital the home effectively shared information about them to ensure their needs were fully understood.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Whilst overall staff concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, and discrimination and neglect and shared concerns where required, we found systems and processes were not always robust. We identified 1 person was at risk of self-neglect and had to report this to the local safeguarding team ourselves. Whilst the concern had been identified and reported previously by the registered manager, this was a few years ago and no actions had been taken to regularly review the situation and keep the person safe. Staff knew who to report their safeguarding concerns to internally and externally. However, they also told us they did not always feel comfortable to raise their concerns to managers as they did not always feel listened to. One staff member said, “Safeguarding means protecting residents from harm, abuse, or neglect. If I notice signs of abuse (e.g., unexplained bruises, sudden behaviour changes), I report it immediately to senior staff or safeguarding authorities.” Where people lacked capacity to make their own decisions regarding where they wanted to live, we found appropriate legal authorisations for Deprivation of Liberty Safeguards (DoLS) were in place.

The provider did not always do everything they could to understand and manage risks. For example, when people routinely declined personal care, assessments had not been completed to identify any risks to their health, safety or welfare. This meant any actions to minimise the likelihood of harm had not been identified for staff to provide care that was safe, supportive and met the person’s needs. We discussed this with the registered manager and reported our concerns regarding 1 person to the local safeguarding team. The registered manager told us they involved people to make decisions to manage risks. For example, a person who kept falling in their room was supported by staff to make the decision to change the layout of their bedroom and this led to a reduction in falls.

Assessments had been completed to identity risks associated with the environment and the equipment people used. However, during our onsite visit we identified hazards that had placed people at risk of harm. Toiletries and topical medicine were accessible in communal bathrooms and could be accessed by people did not have the capacity to understand their safe use. Windows had not always been restricted to prevent vulnerable people from falling and a radiator was not covered meaning a person could be at risk of harm. Several radiator covers had been damaged, this had identified and recorded onto the services’ improvement plan in October 2024, however, effective improvements had not been made by the time of our assessment. The home was cold in some areas and people told us they felt cold. A healthcare professional said, “On a recent visit to the home [person] stated they were cold and was shivering. I spoke to staff who told me there was not a thermometer in the lounge. When I told the staff [person] was cold, they told me “they all say that”, I later heard another resident ask the member of staff to put the heating on.” Following our assessment of the service the registered manager told us digital thermometers had now been placed in all communal areas and bedrooms to monitor the temperatures in the home. Whilst checks on the safety of the environment were carried out and recorded these checks had not identified these concerns. The organisational structure was being changed to provide additional support to maintenance staff.

During our inspection, we observed that the provider had made sure there were enough staff to meet the care needs of people living in the home. However, staff told us that whilst they were a dedicated and hardworking team, they did not always have enough time to fully meet people’s care needs. Staff said, “While staffing has slightly improved, there are some days shifts are unmanageable and means we have minimal time to spend with each resident” , “[People] are not getting the level of care they deserve for example not being offered showers or nail care regularly due to lack of time” and, “It’s very difficult to manage laundry and care when we have a shortage of staff.” People and their families mostly felt there were enough staff to meet people’s needs, however, one relative said, “Staff have told me that there is not enough staff for [loved one] to use the garden. Staff always seem very busy and don’t seem to have breaks.” We discussed this with the registered manager who told us, "We are able to evidence that staffing is in line with the organisational dependency tool and often exceeds the recommended guidance for staffing numbers. The home is supported by an additional 4 staff during day time hours that can support core care team members, in providing assistance to the individuals in the home. These comments are perceptual from staff and visitors and do not reflect the safe staffing numbers on each shift." The provider followed safe recruitment practices and made sure staff training was up to date. One staff said, “When I started working at the care home, I went through a comprehensive induction program that covered both theoretical and practical aspects of care. The induction lasted about one week.” Staff told us their performance was regularly reviewed. One staff member said, “Agincare has given me an opportunity which has enabled me to grow professionally as a confident member of the team.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The home had a cleaning schedule in place and daily checks were made on the cleanliness of the building by managers. These measures had not been effective and we identified that infection prevention and control measures were not being operated in the laundry. For example, the laundry environment was not clean, the sink was not always accessible to staff and bags containing soiled laundry were located directly on the floor. We shared out concerns with the manager however found this practice had reoccurred later during our inspection. There were further concerns around the environment relating to the sluice room, malodour in communal areas and a person’s ensuite being used for storage of furniture and equipment impacting on effective cleaning. The malodour had been identified prior to our inspection and effective action had not been made to ensure improvements were made. Following our feedback, the registered manager told us they had completed their own governance checks and had put in place an enhanced cleaning schedule for the rooms they identified concerns.

The provider mostly made sure that medicines and treatments met people’s needs, capacities and preferences and worked with other healthcare professionals to achieve this. However, systems to ensure medicines were managed safely were not always robust to ensure people were not restricted by the use of as required sedative medicines. As required medicines did not always have a protocol or plan in place to instruct staff why and how the medicine should be administered. When the medicine had been administered, staff had not recorded what happened before, the reason why it had been administered and there was no follow up to record its affect. This meant we could not be assured the medicine had been given as the least restrictive option and in the person’s best interest, this placed the person at risk of harm. Staff were aware of the risks associated with taking high-risk medicines such as anticoagulants and knew what to do if the person fell or cut themselves. Medicines were stored safely and there were appropriate arrangements for disposal, and for controlled drugs. There was suitable temperature monitoring being carried out. Staff training and competency checks were in place and documented.