Trewan House 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 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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The culture of the service ensured people received person-centred care that met their needs and preferences. The provider worked to a core statement of purpose which defined the main aims of the service and fostered a positive work ethos. Staff told us the culture of the service had improved under the new home manager. They were positive about changes that had been made and described how they were all working to a common goal which they felt positively impacted people living at the home. A staff member told us, “The whole atmosphere of the home has improved.”

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. The home manager was newly appointed however, in the short time they had been in their role, they were able to demonstrate their areas of focus and what action they were taking to improve the quality of the service. These actions were fully detailed in an overall service improvement plan. The provider maintained good oversight of all areas of care provision and attended the home regularly to complete quality checks. Staff told us they had confidence in the new home manager’s ability to make positive changes. Comments included, “I’m much happier, feel like a weight has been lifted, it has affected the whole staff team positively, [home manager] is approachable and willing to listen.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Whistleblowing policies and procedures were available to guide staff on speaking up about concerns. Staff told us the previous culture did not support or encourage them to voice their concerns, but they described how this had improved under the new home manager. A staff member told us, “[Home manager’s] door is always open, even if you have an opinion she says come in, sit down, beforehand you couldn’t have shared your opinion, everyone was scared to raise but I’m able to speak up now.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider fostered a positive culture in which diversity and difference was celebrated. Staff told us they now felt more included in the running of the service. We saw how the provider had proposed a change in staff shift times to support people’s morning routines and preferences being met. Records showed how they had consulted staff regarding the change. We found staff feedback was sought to help shape the future running of the service.

The provider had clear responsibilities, roles, systems of accountability and good governance. However, this required further embedding to ensure full effectiveness across the home.Several audits were carried out to keep oversight of the quality and safety of care. Whilst these were largely effective, some of the concerns we noted regarding inconsistencies in risk management plans and concerns with the functionality of equipment had not been picked up through these processes.

The home manager and provider were receptive to our feedback and put measures in place to make immediate changes. While there was no negative impact noted to people, further improvement was needed to strengthen the provider’s governance systems, to ensure they proactively identify and address all risks.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. We saw evidence people achieved good outcomes because of effective partnership working in areas such as falls reduction. Professional partners told us the provider worked in partnership with them and the new home manager was building relationships with professionals, to ensure clear communication and wrap around support was in place.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. There was a strong focus on continuous learning at all levels of the organisation. For example, we saw how the provider had made recent changes to their governance framework to promote better oversight of risk. The provider and home manager embraced the assessment process and used it as a learning opportunity. They took swift action to remedy issues we found to ensure people’s health, safety and welfare. The feedback from professional partners was in line with our findings, as they told us the provider was responsive and engaged well with them, to get the right outcomes for the people living at the home. We were assured effective learning had taken place from our previous assessment to drive the necessary improvements in areas such as medicines management and staff recruitment.