Trewithen

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.
This is the first assessment for this service. This key question has been rated 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.

Relatives were confident the service met people’s needs and provided compassionate support. Relatives’ comments included, “What I can see when I go is very impressive” and “As far as I am concerned the service is really good”.

Staff were dedicated, kind and caring. They felt able to constructively challenge each other and management to ensure actions were consistently taken in each person’s best interest. Staff enjoyed their roles and told us, “I like working here, it is a really nice house” and “It’s great here, a good team, we all club together”.

Professionals recognised the service’s person centred culture positively impacted on people’s wellbeing. They told us, “Staff have been skilled, proactive, flexible and attentive” and “I found the staff to be professional, knowledgeable, and committed to providing high-quality support”.

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.

At the time of the assessment the service did not have a registered manager. A new manager had been appointed to the service and was in the process of applying to become registered . Relatives told us, “The manager is really good” and “I am very impressed with the new manager who seems very good”.

Staff were also complimentary of the new manager and recognised the changes they had introduced were impacting positively on the service’s performance. Staff comments included, “The manager is very nice, been here 3 or 4 months, seems to know their stuff”, “[Manager name] is brilliant…. they have been a breath of fresh air” and “[Manager name] is very good. Not been here that long, still finding their way but is switched on and has had a lot to cope with. I think [they] have done extraordinarily well”.

The provider had recognised the manager was facing some significant challenges and a regional manager had visited the service regularly to offer advice and support. Professionals also recognised that the new manager had made a positive impact in the service. They told us, “Based on my experience, the service appeared to be well-led, with a clear focus on person-centred care and positive outcomes for residents” and [Manager's name] has been pro-active when requesting support or advocating on behalf of [Person’s name]”.
 

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

People were confident while expressing their preferences. Relatives told us they were confident any issues they raised would be investigated. Any complaints received were fully investigated and compliments were shared with the staff team.

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 valued the diversity of their workforce and systems were designed to ensure all staff were treated fairly and with respect. Some concerns had been identified in relation to the culture of the staff team and a regional manager commented, “I think previously there was a bit of a closed culture here”. There were plans to develop a team charter to clearly define expectations of colleagues and help foster the development of a more open, positive and supportive culture amongst the staff team.
Information about the provider’s employee support and assistance plans was available to all staff in the service’s office.

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 service’s quality assurance and auditing processes were effective and designed to ensure people were supported as planned. Records were well maintained and innovative technologies were available to help managers identify possible patterns and trends in incidents that had occurred.
The provider had systems to monitor audit compliance and any issues identified were discussed with the service manager. In addition, a mock inspection of the service performance had been completed and plans developed to address the minor issues identified.
Regional managers and member of the providers support teams attended the assessment and visited regularly to support the Manager. Staff told us, “We have seen quite lot of the regional managers recently”.
 

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.

The service had worked with relatives and health professionals to help ensure care was provided in line with people’s wishes and preferences. Relatives felt appropriately involved in decision making and told us, “Communication is good, the staff call me quite frequently and let me know how [My relative] is doing”.

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.

The provider learned from incidents that occurred and, where possible, developed plans to limit the impact of future similar events. A significant storm which caused widespread damage locally had left the service without electricity or water for over 48 hours. As a result, people living in the service had moved to other local services operated by the provider until repairs were completed. Staff had been debriefed following this incident. Learning and improvements suggested had been acted upon, resulting in changes to the provider’s policies and emergency plans.