Trafalgar Community Care Limited

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection this key question was rayed good. At this inspection this key question has remained the same. 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 68 (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 provider had a positive culture that focused on person-centred care and supporting people to remain independent at home. Feedback from people and relatives consistently described the service as caring, safe and responsive, with staff described as “kind”, “patient” and “like family”, demonstrating a strong values-based culture.

Leaders promoted a culture where people’s preferences, routines and emotional wellbeing were valued.

Staff and relatives spoke positively about the service, with many reporting no improvements were needed around culture and highlighting the supportive and organised nature of the service.

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.

Leaders were described by people as approachable, responsive and supportive, and were well regarded by staff and people using the service. Staff consistently told us they felt supported by management and that concerns were listened to and acted upon. One member of staff said management were “very approachable and friendly whilst always looking to help.”

People and relatives also spoke highly of the registered manager, describing them as proactive and attentive, regularly checking in with them.

There was evidence leaders promoted inclusive working, with staff reporting they could raise issues, seek advice and access training relevant to their roles.

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

Policies supported this approach, including a whistleblowing policy which clearly outlined how to escalate concerns and protected staff from victimisation.

Staff responses demonstrated awareness of safeguarding and reporting processes and confidence in escalating concerns internally and externally if needed. One staff member told us they would escalate concerns to management and, if unresolved, would contact external organisations such as the regulator.

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 described management as approachable and supportive, and feedback indicated staff felt comfortable raising concerns and discussing issues.

Systems such as on-call support ensured staff had access to advice and guidance, including outside of normal working hours.

The provider did not always have clear governance arrangements in place, including defined roles, responsibilities and systems of accountability. They did not always use information about risk, performance and outcomes effectively to support oversight and improvement.

Although governance systems had identified some areas for improvement, including medicines and person-centred detail, further work was needed to strengthen oversight and ensure gaps in service provision were consistently identified and addressed.

This included gaps in the recording of risk assessments, minor shortfalls in recruitment records, and limited documented analysis or learning from incidents and accidents.

The provider worked closely with staff and regularly visited people, which supported oversight, although this was not always formally recorded. They had started to make improvements before our inspection and had identified areas for development. Following the inspection, the provider shared an action plan showing how these issues were being addressed.

The provider understood their duty and worked in partnership with other health and social care professionals to support people’s wellbeing.

There was evidence of effective collaboration with GPs, community matrons and paramedics, with staff monitoring people’s health and escalating concerns appropriately.

Care planning and service delivery reflected a coordinated approach, supporting people to remain at home and access the healthcare they needed. Feedback indicated this partnership working had a positive impact on outcomes for people.

The provider was focused on continuous learning, innovation and improvement across the service and wider local system. However, some improvements were not always made or recorded in a timely way.

Systems were in place to support improvement, including changes to medicines processes and the introduction of a new electronic care planning system. However, learning identified through internal systems was not yet consistently documented. Since the inspection, the provider has acted on our feedback and addressed several areas for improvement.