Trafalgar 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 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 requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance and management oversight.

This service scored 50 (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, and engagement. However, this was not fully embedded and effectively shared with staff. Managers and leaders did not always fully understand the challenges and the needs of people and their communities.

We found improvements were made since the last inspection as to how well the service was managed and led. Leaders and managers had shaped its culture by engaging with staff, people who use services, carers and other stakeholders. However, although improved, was still not always effective. For example, staff did not always demonstrate a good understanding of the service’s vision, values and strategic goals. Evidence showed managers and staff did not always share an understanding of the risks and issues facing the service. The manager told us the service strived for their goal of continuous improvement with strong focus on achieving their goals and aspirations, improving quality and safety, valuing their staff and understanding people using the service. They told us that one of the provider’s key values was person-centred care however people and their relatives told us they did not always feel included or involved in planning their care. Staff did not always ensure people were at the centre of their care and did not always work in partnership with them or empower them to make decisions about how their care was delivered. Care plans lacked person-centred details and did not always reflect all people’s needs, preferences, life histories and long-term aspirations.

Relatives expressed their concerns about culture. Comments included, “There is a lack of communication right from the top. The staff are not treated well; they have a lack of direction and seem to be left to their own devices.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Although significant improvements were made to the way the service was managed, there was still instability within the leadership of the service and the management structure in place was not fully established at the time of our inspection. When we inspected, the new manager had been acting up for few months before applying for their registration and there was ongoing recruitment into the vacant deputy manager’s post. We received mainly positive feedback from staff about the manager. Most staff told us they are approachable, supportive and lead by example. Comments included,“[Manager’s name] has really worked hard along with the team to try and pull this place to a better standard. In the short time I have seen major improvements to how things are done and the morale of the team.”

Although the manager had a good understanding of CQC requirements, in particular, to notify us, and where appropriate the local safeguarding team, of incidents including potential safeguarding issues, disruption to the service and serious injury, this knowledge had not always been applied into practice in their absence. Cover for the absent manager did not always ensure consistent leadership. Managers and staff had not always shared an understanding of the risks and issues facing the service. For example, monitoring of daily care delivery or oversight of comprehensive care planning and needs assessments by the managers were unreliable or inconsistent.

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

At our last inspection staff told us they did not always feel listened to and in some cases, told us they had stopped speaking up because they did not feel safe to do so.At this inspection we found vast improvements were made to foster a more positive, open and transparent culture. Staff surveys and team meeting minutes evidenced staff had been given the opportunity to speak up and drive improvements. There was a positive culture of speaking up where staff felt confident to actively raise concerns and those who did (including external whistleblowers) were supported, without fear of detriment. Leaders were open to feedback, and staff felt supported and encouraged to speak up and raise concerns about quality of care. Staff were aware of the term ‘freedom to speak up’ and how to execute this freedom. We saw posters around the premises actively encouraging staff to voice concerns and to take part in an annual staff survey.

Staff told us, “[The manager] always listens to our problems and try to solve them. [They] always stand with us.”

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.

At our last inspection staff told us they did not always feel empowered and confident that their concerns and ideas resulted in positive change to shape the service and create a more equitable and inclusive organisation.At this inspection we found vast improvements were made to foster more inclusive and fair culture by improving equality and equity for staff.

The provider had policies and procedures supporting diversity and inclusion within the service and promoting diversity and inclusion in the workforce. Policies and training materials had been translated into different languages to ensure staff understood them. Staff in various roles within the home were from diverse backgrounds. Leaders made reasonable adjustments to support staff with protected characteristics to carry out their roles well. Staff received training in equality, diversity and inclusion; the completion rate was 100% when we visited. Staff told us they would care for anyone if they needed it, regardless of their backgroundwithin their service.

The provider did not have clear responsibilities, roles, effective systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance, accountability arrangements and quality assurance systems had improved significantly since our last inspection. However, management systems were still not always robust and consistent in identifying and managing risks to the quality of the service. Processes were in place to ensure the service operated safely but they were not always effective. Audits at provider level had not identified the shortfalls found within the inspection.

Quality assurance systems did not always operate effectively in helping to ensure people consistently received safe and good quality care and support. For example, monthly medicines audits were completed however they didn’t identify concerns relating to the high-risk medicines such as anticoagulants. Risks associated with blood thinning medicines were not identified and effectively mitigated for all people they were prescribed for.

When the provider’s quality assurance processes identified issues, this had not led to improvements and risk mitigation measures were either not implemented or were ineffective. For example, ‘Provider Visit Monthly Report’ dated 11 September 2025 identified a lack of relevant risk assessments for people with diagnosis of diabetes. People’s care plans did not always provide details regarding to what their diabetic diet entailed, and people’s tissue viability care plan did not always mention the known risks to skin integrity associated with diabetes providing guidance for staff as to what to raise concerns about. When we visited on 4 November 2025, we reviewed care plans for 4 people with diagnosis of diabetes and found different parts of their care plans were not effectively coordinated to ensure consistently positive outcomes for them. Some people still did not have complete and accurate risk assessments in place to reduce the risks of health complications caused by diabetes and were at risk of health deterioration.

This meant the provider’s quality assurance processes needed further work to operate effectively, as opportunities for further improvement and development had been missed, and people remained at risk of harm.

The provider did not fully understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not effectively and consistently share information and learning with partners or collaborate for improvement.

The service was not fully involved in the community, and no consistent efforts were made by the provider to foster positive relationships with the community and collaborate in partnership working. Staff and leaders did not always engage with people, communities, and partners to share learning with each other that resulted in continuous improvements to the service. These networks were not always used to identify new or innovative ideas that could lead to better outcomes for people, and the manager recognised the need for more collaborative partnership working to drive improvements.

We received mixed feedback from partners about collaboration and joined up working with the service. Partners commented on difficulties in communication which can potentially lead to delays in treatment. Comments included, “Communication is often the biggest barrier, and sometimes the care home don’t follow the correct protocol of phoning to refer a patient to our service” and “The care staff are often unable to update us with the longer term plans for residents who are there on a temporary basis, we can only get this information from the manager. There is not always a member of the management team on duty when we conduct visits, which would improve the communication between the home and external services, including health.”

We received mixed feedback from relatives about management and leadership. Relatives felt the management of the service was inconsistent and did not always effectively guide their team to deliver safe and compassionate care. Comments included, “I have given up raising issues as they just fall on deaf ears. If you phone, no person from management is there to deal with it and they don’t get back to you if you leave a message.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff told us they felt more involved in developing and evaluating improvement and innovation initiatives. Staff felt this had improved recently with the new management team in place. Comments included: “My manager has always been very supportive, even when [they] were the deputy manager. At that time, we didn't have any other manager or team leader, and [they] supported the whole team. [They] made it easy for staff to approach [them] with anything and always ensuring that the people we support received the best care.”

The manager told us they recently commenced a collaboration with Plymouth University on one of their ‘Dietetics, Human Nutrition and Health’ projects to learn how optimal nutrition can be maintained during older age. Managers actively encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. This resulted in more trust developing between leadership and staff. However, the culture of reflective practice and collective problem-solving was not fully embedded. Staff and leaders had not consistently demonstrated a good understanding of how to make improvement happen. There were processes to ensure learning when things went wrong, and from examples of good practice, however they were not always effective. The approach was inconsistent and had not always included measuring outcomes and impact.

Improvements were not always identified, and where they were, action was not always taken or identified shortfalls were not always rectified in a timely way and lessons learnt had not always been effectively shared with all staff to prevent re-occurrence. Improvements were not fully embedded and sustained in practice. For example, we found staff lacked full understanding and awareness of how to monitor and record correct settings for pressure relieving mattresses. This had placed people at risk of not having their care needs met or risks of harm identified to prevent a re-occurrence.