Trafalgar Care Home

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent 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 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders did not always ensure there was a shared vision and strategy that staff in all areas knew, understood and supported. The registered manager told us the providers values were, “They are about providing good quality care, to excel in everything we do, to support each other. Value staff, achieve our goals and aspirations. Learn and encourage a culture of knowledge, expertise and accountability, understand the business and our customers.” Staff we spoke with did not always provide feedback that aligned with these values. They told us people were at the heart of everything they did, however, they did not always feel included in the shared direction and culture of the service. The mixed feedback we received from staff included, “I feel proud to work at Trafalgar Care Home because of the impact we make on residents’ lives, the supportive and compassionate team environment. It’s a place where I feel valued, part of a family, and able to contribute to something truly meaningful” , “We are not getting adequate support. Staff are always very stressed and moral is very low.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. However, staff told us they did not always feel they could report their concerns to the management team, and this had placed people at risk of not having their needs met. At the time of our assessment, the registered manager had just ended a period of time where they had split their time and attention at work across two care homes. This may have contributed to why staff felt they were not always supported and the inconsistencies we identified in the delivery of care. We found the registered manager to be knowledgeable, caring and inclusive. The registered manager told us “[the provider] is very supportive, I am currently finishing my level 5 in health and social care leadership, I’ve completed management training at head office and learned a lot, I have regular supervisions and appraisals and can ask for any additional training if I felt I needed it.”

Staff did not always feel they could speak up and that their voice would be heard. They did not always feel there was a no blame culture and therefore did not always feel comfortable to raise their concerns with leaders. The provider and registered manager had systems in place to enable staff to speak up. Staff were aware of these systems, however, told us they did not always feel listened to and in some cases, told us they had stopped speaking up because they did not feel safe to do so. Feedback we received included, “staff are worried to tell their concerns” , “Management listen to all our concerns, and they try to solve it as much they can” and, “Staff have stopped going to management with their concerns as they feel it’s pointless.”

Leaders mostly valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. For example, policies and training materials had been translated into different languages to ensure staff understood them. The registered manager told us they provided opportunities to involve staff in the running of the service, with a focus on hearing the voices of staff with protected equality characteristics and those who are excluded or marginalised, or who may be least heard within their service. However, staff did not always feel this way. Staff told us they did not always feel empowered and confident that their concerns and ideas result in positive change to shape the service and create a more equitable and inclusive organisation. One staff member said, “I love caring for my residents, but I don’t feel comfortable to raise my concerns, we got a survey from head office but there was no improvement from them.”

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, or share this securely with others when appropriate. Governance systems with either not in place or were not effective at identifying the shortfalls we identified. These shortfalls were repeated concerns previously identified in our inspections and in the local authority monitoring visits. We discussed our findings and concerns with the nominated individual for the provider. They said, “We are obviously disappointed to hear about your findings. We will be investigating and will ‘red flag’ the home which means we will be sending our governance teams to support the service and bring it in line with the standards of care we expect.” Following our assessment and feedback, the registered manager said, “As a team we are aware of the requirements that need to be made in the service and are dedicated in turning this around within the home, I feel that now I have returned to the service in capacity as manager on a full time basis that these will be monitored and progressed swiftly to ensure suitable change and I will be dedicating my time to ensure there will be sustainable oversight for the foreseeable.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, improvements were required to ensure learning was embedded and sustained to ensure the service continuously learned and improved. The registered manager told us they were open and transparent. Information was shared with the local authority including social workers and the quality improvement teams. The registered manager attended weekly multi-disciplinary professional meetings to discuss and share learning. Learning however, had not always been embedded into the service leading to us identifying shortfalls at the service. The registered manager told us, “We are looking to develop our community engagement and links to services. We have organised some visits from the local church, and we are looking forward to the summer when we will be having visits from Art escape, this is an art class for our residents in a group setting however can be tailored as a one to one if required.”

Leaders systems and processes did not always support continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Staff did not always feel the service actively involved them in understanding how to make improvements and collective problem solving, including when things go wrong. After our assessment the provider told us their plans for the future, “We are preparing for the rollout of our quarterly quality themes across Agincare, beginning in March 2025.” These included 4 key themes, Shared Direction & Culture, Learning Improvements & Innovation, Capable & Compassionate Leadership and, Community and Partnership. The provider said, “This initiative presents a wonderful opportunity for mutual learning and development.”