Trafalgar Care Home

We carried out our on-site assessment on 4 November 2025. Off-site activity started on 5 November and ended on 21 November 2025. During the inspection we assessed the quality statements under all key questions of safe, effective, caring, responsive and well-led. We conducted this assessment to review an action plan request issued in March 2025. The provider was in breach of the legal regulations relating to good governance, premises and providing personal care.

At our last assessment in February 2025, we found the provider did not always demonstrate a good learning culture. The environment was not always safe and well maintained. The home was not always clean and free from the risk of infection. Risks to people were not always understood and managed. Systems to ensure medicines were managed safely were not always robust. People and their relatives told us they were not always involved in the reviews of their care. These were breaches of regulation.

At this assessment, quality of care plans and risk assessments had improved however they lacked person centred details. People’s personal, cultural, social and religious needs were not always documented or understood by all staff. Care plans did not include information about people’s strengths, abilities, personal goals and aspirations. Staff had limited access to information about the full context of people’s life experiences, their life history, personal, cultural, social and religious needs and on how to tailor people’s care and support accordingly. Relevant health and safety concerns were not always included in people’s care plans. Improvements were made by the provider on how to assess and reduce the risk of injury caused by people’s living environment since our last inspection.
We found the service to be generally clean when we visited however the malodour in the communal areas was still present. Actions taken to address malodours were ineffective to ensure improvements. People’s medicines were seen to be given in a safe and caring way. However, we found the provider’s medicine management policy had not always been followed, and there were still areas of medicines processes that needed to be improved.

At our assessment in February 2025, we found the leadership, governance and culture had not always supported the delivery of high-quality, person-centred care and the provider's monitoring processes were not always effective. Managers did not have full oversight of the service to monitor quality and safety. Staff did not always feel supported or listened to and did not always feel there was a no blame culture. This was a breach of regulation.

At this assessment, we found there had been a continuous lack of consistency in how well the service was managed and led. Staff told us this had led to improvements in the support they received; staff felt more involved, valued and listened to. Governance, accountability arrangements and quality assurance systems had improved significantly. However, management systems were still not always robust and effective in identifying and managing risks to the quality of the service. Audits at the provider level had not always identified the shortfalls found within the inspection.

The provider remains in breach of the regulations relating to person-centred care, safe and clean premises free from odours that are offensive or unpleasant, and management, oversight and governance.

We asked the provider to submit action plan for the areas in breach of regulations.