Trembaths

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 the last inspection, we rated this key question as good. At this inspection this key question has remained 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.

Staff were positive about how the team supported people live their best lives. A staff member said, “I appreciate the opportunity to work at Trembaths and support the residents. One of the most important strengths of a care service is having staff who are caring, patient and committed to residents’ wellbeing.”

The provider had a service improvement plan in place. This managed areas identified by the team as needing improvement and also included new ideas to further improve people’s experiences and staff skills.

Feedback from people and their relatives was obtained through meetings, surveys and care plan reviews. In addition, people, relatives and visitors told us the registered manager was available, approachable and helpful. Meetings were held with staff to share and receive information.

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.

People and relatives were positive about the registered manager and staff team. A relative said, “I know the manager, they usually walk around the home first thing in the morning and is always available to talk to help support the family as well as the resident, he has been a great support for [family member of person] who was out of their depth with [person's] diagnosis of dementia.”

Staff were positive about the culture and approach in the home. A staff member said, “The teamwork and resident-first culture are particularly good. Communication can always continue to be optimized as we grow, but overall, it is an excellent service.” Staff told us they would have a relative of theirs live at the home. The registered manager told us they were happy with the quality of the staff team and the care they deliver.

There were systems in place to help ensure care was personalised and people had a positive experience. A function of the provider’s system included an overview of people’s involvement and engagement with activities, social interaction and time with family or friends and general wellbeing. Where this needed more input from staff, actions were developed for staff completion. For example, person centred care training.

The provider fostered a culture where people felt they could speak up and their voice would be heard.

Staff said the registered manager engaged with and involved them. A staff member said, “The service is well-run. Management conducts regular spot checks, actively asks for our views, and I feel entirely free to speak up.”

Staff told us the management team were visible and approachable.

There were resident, relative and staff meetings. A survey for people, relatives, and staff had been carried out. Actions were implemented and recorded where needed in response to feedback. These were included on a ‘You said, We did’ notice board. This included information about the requested physical activities which had been added and a new bookcase for a book swapping library. A further survey had recently been completed and the responses were being collated.

Relatives had regular contact with staff and managers, and during assessment, care planning and events in the home. This enabled effective communication and sharing of feedback.

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.

Staff felt supported and respected by the management team. A staff member said, “People and staff are treated fairly, equally and with respect, regardless of their background, culture, beliefs or individual needs. I believe everyone deserves equal opportunities, dignity and person-centred care without discrimination.”

The provider had an equal opportunities policy which they adhered to. Staff employed demonstrated different backgrounds, ages, genders and ethnicity which was a benefit for the people they supported.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. However they needed to adapt their approach to identify gaps in records in the future.

There were governance systems to help identify and address any issues. These systems covered key areas such as care plans, health and safety, clinical needs, falls and medicines. Where issues were found, a plan was developed and actions taken to resolve it. However, the areas needing improvement we identified as part of this inspection in relation to continence and positioning records, had not been identified as part of the governance systems. We discussed with the registered manager and the deputy manager. Following our feedback the management team implemented immediate actions to address the points raised and these were in progress at the time of this report, giving assurances remedial work would be completed. This included adding a task to all care plans to alert staff to missed care or a missed care entry and meetings with all staff to address the shortfalls.

Staff were positive about the management and running of the service. A staff member said, “I feel the service provides good care and support, with staff treating people with kindness, dignity and respect. We work together as a team to meet people's individual needs, respect their choices and help them feel safe and comfortable. I am happy to be part of a team that supports people's wellbeing and aims to provide the best possible care.” Another staff member said, “I appreciate my manager and the positive working environment. I would recommend Trembaths as a place to work.”

The management team responded to any complaints, feedback and requests.

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.

People and relatives told us they were supported to access other professionals.

Visiting health and social care professionals were positive about the service. One said, “Staff have consistently been friendly, welcoming, and supportive, and I have not had any concerns regarding the care provided to residents. During my most recent visit, the manager took time to speak with me following an assessment and demonstrated a good knowledge and understanding of the resident we were discussing. This reflected a person-centred approach to care.”

The management team worked with agencies outside of the organisation. This included health and social care agencies and benefitted people and the service. This included a care providers association to access training and updates, and other health and social care teams so health care and support were accessible.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff told us information was shared and training provided to drive improvements and innovation. A staff member said, “Regular checks, staff meetings, supervision and opportunities to share feedback help identify areas for improvement. It is important for staff to be informed about changes to policies, procedures and legislation. Learning from incidents, complaints, safeguarding concerns and inspections helps improve the quality and safety of care.”

The provider had developed systems to help identify any learning and improvement areas. They had plans to further improve people’s experiences.