Trinity House

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.

The registered manager promoted values of compassion and kindness, encouraging independence in a person-centred way. The registered manager said, “Our values are to ensure people have a good quality of life. By listening to people’s preferences, promoting independence and development means we can support people to have a meaningful life. It is so rewarding to see people gaining new skills and achievements.”

Staff we spoke with were committed to the same values and placed people at the centre of their support. Staff described how they were led by people’s wishes and preferences, whilst promoting their independence. One staff member said, “We have an amazing team who all have the same values and work well together to ensure he people we support are in control of their lives.” This demonstrated a positive culture and shared commitment to delivering inclusive care which responds to the needs of people living at 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.

Staff told us the registered manager was approachable, supportive, and listened to them, acting on any issues they had raised. Staff were encouraged to reflect on their practice and share ideas to enhance the quality of care provided. Regular training, team discussions, and supervisions were used to identify areas for personal development and improvements to service delivery.

The registered manager and provider were described as caring and had developed positive relationships with the people who lived at the service. One person said, “[Registered manager’s name] is great, this is the best place with the best manager. I look forward to them coming on shift.” The provider’s approach helped create an environment in which staff and the people supported were treated with respect and felt valued.

The team culture was positive with staff expressing pride in the service. One staff member said, “It is a friendly loving atmosphere, people are supported in a person-centred way. I would recommend living here.” Another staff member said, “I enjoy supporting and enabling people with their independence, experiencing new things to do in the community. Building relationships and forming mutual loyalty and respect for one another builds trust, this can help to stop any barriers as there is mutual trust.

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

Staff were confident in raising concerns when needed and understood the different ways they could raise these internally and externally. One staff member said, “It is really important staff feel able to speak up, we have whistleblowing procedures and I feel confident I could speak up because [registered manager’s name] is open and approachable. I know they would take action to make sure people were safe.” This demonstrated a culture of openness and integrity within the service.

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 explained the importance of respecting people’s diverse needs and ensuring they promoted an inclusive and fair place for people to live and staff to work. The inclusive culture within the service helped to ensure all staff felt valued and respected, and the care delivered was reflective of the diverse needs of both the workforce and the people supported.

The training records showed staff received Equality, Diversity, and Human Rights (EDHR) training and we observed their understanding of this in the support provided to people. Staff understood diverse cultures, races, and identities, and this was embedded in the service’s values and approach. The provider promoted diversity and inclusive recruitment, ensuring adjustments were made to support accessibility and inclusivity for all staff.

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.

Regular audits were carried out by the registered manager to monitor and manage the quality of the service. The audits were completed under each of CQC’s key questions of Safe, Effective, Caring, Responsive and Well Led, which monitored the provider’s compliance with Regulations and helped to drive ongoing improvement. Clear actions were recorded allowing the service to track progress and maintain oversight. This demonstrated a commitment to accountability, learning, and delivering a good standard of care.

Accidents and incidents were recorded in detail, and discussions held with staff to reflect on their practice and ensure risks were managed and mitigated effectively. Weekly key‑worker sessions gathered people’s feedback and reviewed their support, encouraging their involvement in service improvements. Staff feedback and suggestions were gained during team meetings and supervisions to provide opportunities for them to be involved in shaping the service.

The registered manager continuously updated their knowledge and skills through national provider events, workshops, and registered manager meetings. The registered manager said, “I find going to events where other providers and managers are in attendance is a helpful way to share good practice and learn from each other. I then share this with the staff team and discuss in meeting so we can all benefit from the learning.”

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 regularly engaged with local health professionals, advocacy groups, and the wider community to ensure people had access to a broad range of services and opportunities. For example, the staff supported people to engage and feel part of their local community by regularly going out to do their favourite things such as bowling, accessing the gym, and going for a drink at the local pub. This reflected a commitment to person-centred care and improving outcomes through access to health and community services.

The registered manager had developed strong working relationships with a range of health and social care professionals and sought new partnerships where people required specific input. This included social workers, GPs, dentists, healthcare support, community recovery groups, and counselling. This demonstrated a focus on collaboration with other professionals and agencies to ensure people were supported to maintain their health and wellbeing.

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 promoted ongoing improvement, listening to advice and feedback to ensure people received support which met their individual needs. They fostered a culture of openness, learning and improvement when things went wrong. The registered manager said, “I welcome feedback from professionals, and we have built good relationships with external agencies. Their input is helpful and an important part of our focus to continuously learn and adapt.”

Staff confirmed feedback received by the registered manager was shared with the team so they could make improvements to the support people received. One staff member said, “The registered manager always shares feedback or improvements with us. It is a positive environment for people and staff.”