Trepassey Residential 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 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 75 (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, people and family members spoke positively about the leadership of the service and described the management team as approachable, supportive and responsive. Staff told us they felt valued and were encouraged to raise concerns, share ideas and contribute to service development.

There was a positive and inclusive culture within the service. Staff consistently described good teamwork and open communication. One staff member told us, "We help each other whenever we can," while another said, "This is a really lovely place to work."

Staff had developed positive relationships with people and knew them well. This helped to ensure care remained consistent, person-centred and focused on achieving good outcomes. The supportive culture within the service contributed to positive experiences for people and promoted the delivery of high-quality care.

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 management team had worked at the home for many years and knew people, staff and families well. This provided continuity and stability, including during a planned transition of responsibilities to the home manager, who was preparing to register with CQC. The registered manager was still working at the service.

People, family members and staff spoke positively about the leadership of the service. Leaders were described as approachable, supportive and responsive. One family member told us, "The manager has always been incredibly friendly and approachable."

Staff said they felt valued and well supported. They described leaders as visible, accessible and actively involved in the day-to-day running of the home. One staff member told us, "I can always speak to a manager and seek any support or guidance I need."

Leaders promoted an open and inclusive culture where staff felt able to raise concerns, share ideas and contribute to improvements. Regular meetings, supervision and effective communication helped support high-quality, person-centred care.

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

The provider had a clear speaking-up culture and staff were aware of their responsibilities to raise concerns. Staff told us they felt confident their concerns would be listened to and acted upon.

Managers encouraged an open and transparent culture where staff felt able to challenge practice constructively and hold one another accountable. Staff described how they would address concerns directly with colleagues and escalate issues to managers where necessary. One staff member told us they would speak privately with a colleague if they observed poor practice and report ongoing concerns to a manager for follow-up.

Staff and leaders demonstrated openness, honesty and transparency in their approach. The provider understood its responsibilities under the duty of candour and the importance of being open and honest when things went wrong.

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 told us they were treated fairly and with respect and felt valued by leaders. They described a positive and inclusive culture where they were supported to develop and contribute to the service.

The provider employed a diverse workforce and promoted equality, diversity and inclusion. Staff received training in equality, diversity and human rights, helping them to understand people's individual experiences, challenge discrimination and provide inclusive care. Regular training and ongoing support helped ensure staff understood their responsibilities and promoted a culture where both people using the service and staff were treated with dignity and respect.

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.

The provider had effective governance systems in place to monitor the quality and safety of the service. Regular audits and checks were completed across key areas, including care planning, medicines management, infection prevention and control, and health and safety. Daily oversight and observations supported consistent care delivery and helped identify areas for improvement.

Audit findings were reviewed and acted upon, with clear follow-up to ensure identified issues were addressed and improvements sustained. This demonstrated a commitment to continuous improvement and maintaining high standards of care.

The provider understood and met its regulatory responsibilities. Statutory notifications were submitted to CQC as required, supporting openness, accountability and effective oversight of the service.

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.

Staff worked closely with people, family members and a range of health and social care professionals to ensure care was coordinated and responsive to people's needs. Information was shared appropriately with relevant professionals to support continuity of care and ensure people received consistent support.

Professionals spoke positively about working with the service and described staff as knowledgeable and responsive. One healthcare professional told us, "Staff know people well, they are proactive and good at raising concerns in a timely manner."

Records demonstrated staff sought advice promptly, acted on professional recommendations and maintained effective communication with external agencies. This helped to ensure people received joined-up, person-centred care that reflected their individual needs and supported positive outcomes.

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.

Effective quality assurance systems were in place to monitor the quality and safety of the service. Leaders used audits, incidents, feedback and regular oversight to identify improvements and drive positive change.

Lessons learned from incidents, accidents and safeguarding concerns were shared with staff and used to improve practice. Staff told us leaders encouraged their ideas and were committed to continually improving the service.

The registered manager and leadership team demonstrated a commitment to learning and development. This helped to promote a culture of continuous improvement and supported the delivery of high-quality, person-centred care.