Twyford House. Voyage 1 Limited. Overall rating for this service. Inspection report. Ratings. Good

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1 Voyage 1 Limited Twyford House Inspection report Whitfield Avenue Dover Kent CT16 2AG Tel: Date of inspection visit: 14 July 2016 Date of publication: 19 August 2016 Ratings Overall rating for this service Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? 1 Twyford House Inspection report 19 August 2016

2 Summary of findings Overall summary This inspection was carried out on the 14 July 2016 and was unannounced. Twyford House is registered to provide accommodation and personal care for up to 14 people. One person lived in an annexe to the main house, on the same site. People living at the service had a range of learning disabilities. Some people had physical disabilities and required support with behaviours which challenged. Downstairs there was a kitchen, dining room, lounge and two conservatories. There was also a toilet and washroom. There were 12 bedrooms split over two floors, many of which had an ensuite bathroom. The annexe had it's own bedroom, bathroom, kitchen and lounge. At the time of the inspection there were 11 people living at the service and one additional person living in the annexe. The service had a registered manager in post. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations, about how the service is run. Staff were checked to make sure they were of good character and suitable to work with people. Further details of how decisions were made to employ staff who may need to be monitored were not in place. This was an area for improvement. Staffing levels were flexible depending on the needs of people and what was happening that day. People were able to access the activities they wanted and any appointments as necessary. Staff completed incident forms when any accident or incident occurred. If there were any incidents of behaviour that challenged these were reviewed by the provider's behavioural therapist to look for any trends or potential triggers. Risks relating to people's health, their behaviour and other aspects of their lives had been assessed and minimised where possible. Regular health and safety checks were undertaken to ensure the environment was safe and equipment worked as required. Regular fire drills were undertaken. Staff knew how to recognise and respond to abuse. The registered manager had reported any safeguarding concerns to the local authority and these had been properly investigated. Medicines were stored appropriately. People received their medicines when they needed it and were encouraged to be as independent as possible when taking their medicines. Staff had received induction, training, support and supervision to support people effectively. The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are a set of checks that are designed to ensure that a person who is deprived of their liberty is 2 Twyford House Inspection report 19 August 2016

3 protected, and that this course of action is both appropriate and in the person's best interests. Some people had DoLS in place and the conditions on these DoLS, such as accessing external activities was being met. Staff had up to date knowledge on the Mental Capacity Act 2005 (MCA) and DoLS. They supported people to make their own choices where possible and best interest meetings had been held when people could not consent to the support required to manage their behaviours safely. People were supported to eat healthily. They were involved in planning and preparing meals. People were seen and assessed by a speech and language therapist (SALT) when they needed support to eat and drink safely. Staff had sought advice and guidance from a variety of healthcare professionals to ensure people received the best care possible. People and their relatives said that staff were kind and caring. Some people were unable to communicate verbally but staff anticipated their needs and understood their non verbal methods of communication. People were treated with dignity and respect and staff knocked on people's doors before entering. Staff were responsive to people's needs. Before people moved into the service a detailed assessment was carried out and staff added to this as they got to know people better. There were behavioural support plans in place outlining potential triggers for behaviour that challenged and different strategies to deal with them. We saw these being followed. People had helped to write personalised communication passports that told staff how to communicate with them effectively. People accessed a variety of activities both inside and outside of the service. Some people volunteered at the East Kent Railway Trust and others attended social groups and sensory sessions. There was a complaints policy in place and people's relatives said they knew how to complain if they needed. The registered manager recorded any concern or area for improvement as a complaint to ensure it was investigated fully. The actions taken were documented and shared with staff. Staff and relatives told us they thought the service was well led. The registered manager was experienced in working with people with learning disabilities and providing person centred care. The Care Quality Commission (CQC) had been informed of any important events that occurred at the service, in line with current legislation. The registered manager told us the ethos of the service was, "Flexibility with the underlying structure. We can plan and make sure people know what they're doing, but for the people we support things can change, their needs can change and we need to be able to adapt to that too." There was a culture of openness and honesty and staff responded to the needs of people as they changed. The registered manager and the area manager regularly carried out audits to identify any shortfalls and ensure consistent, high quality, personalised care. People, their relatives, staff and other stakeholders were regularly surveyed to gain their thoughts on the service. The results of these surveys were collated and any areas of improvement were identified and actioned. 3 Twyford House Inspection report 19 August 2016

4 The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? The service was safe Checks were carried out on people before they started work, further details of how decisions were made to employ staff who may need to be monitored were not in place. There was enough staff to meet people's needs. Potential risks to people had been identified and recorded and there was clear guidance in place to help manage the risks. Regular checks were carried out on the environment and equipment to ensure it was safe and fit for use. Staff had received training and knew how to recognise and respond to different types of abuse. Medicines were managed safely. People were encouraged to be as independent as possible with their medicines. Is the service effective? The service was effective Staff received induction, training, support and supervision to support people effectively. Staff had an understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Some people had DoLS in place and conditions relating to these were followed. People were supported to prepare and eat wholesome and nutritious food. People regularly saw healthcare professionals. There was guidance in place to ensure people were supported with their health needs. Is the service caring? The service was caring People and their relatives said that staff were kind and caring. 4 Twyford House Inspection report 19 August 2016

5 Some people were unable to communicate verbally but staff anticipated their needs and understood their non verbal methods of communication. People were treated with dignity and respect and staff knocked on people's doors before entering. Is the service responsive? The service was responsive Assessments were carried out before people moved into the service. People had guidelines in place to support them with their behaviour and personalised communication passports. People volunteered at the East Kent Railway Trust and participated in a range of activities inside and outside of the service. There was a complaints policy in place. The registered manager treated any concern or area for improvement as a complaint to ensure it was investigated fully. Is the service well-led? The service was well-led The registered manager had worked with people with learning disabilities for over 20 years. The Care Quality Commission (CQC) was informed of important events within the service, in line with current legislation. Staff were aware of the provider's values to provide person centred care. The registered manager and the area manager undertook regular audits to ensure consistent, high quality, personalised care. They regularly surveyed people, their relatives and other stakeholders to gain feedback. 5 Twyford House Inspection report 19 August 2016

6 Twyford House Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act This inspection took place on 14 July 2016 and was unannounced. It was carried out by two inspectors. The provider had not had the opportunity to complete a Provider Information Return (PIR) as they had not received this document prior to the inspection. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We looked at previous inspection reports and notifications received by the Care Quality Commission. A notification is information about important events, which the provider is required to tell us about by law. We spoke with the registered manager and the deputy manager. We spoke with four additional members of staff. We looked at five people's care plans and the associated risk assessments and guidance. We looked at a range of other records including five staff recruitment files, the staff induction records, training and supervision schedules, staff rotas, medicines records and quality assurance surveys and audits. We spoke with two people who lived at the service and five relatives. We observed how people were supported and the activities they were engaged in. After the inspection we spoke with the local safeguarding co-ordinator about the service. Some people were unable to tell us about their experience of care at the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us We last inspected Twyford House on 26 February 2014 when no concerns were identified. 6 Twyford House Inspection report 19 August 2016

7 Is the service safe? Our findings People told us and indicated that they felt safe living at the service. People were relaxed in the company of staff and staff responded quickly when people became distressed or anxious. People's behaviours were managed safely. Staff knew people well and said they had built up good relationships with the people they supported. One relative said, "Since they moved in, I haven't had any worries about their safety." Written references were obtained and checks were carried out to make sure staff were of good character and were suitable to work with the people. Disclosure and Barring Service (DBS) criminal records checks had been completed. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services. Further details of how decisions were made to employ staff who may need to be monitored were not in place to ensure they did not pose a risk to people in the service. This was an area for improvement. People's relatives said they felt there were always enough staff to meet people's needs. They also said "There is a good variety of staff as some people work well with different people and there will always be someone that people get on with on a shift". Another relative said, "There always seems to be enough staff here." The service had a flexible staffing rota which changed according to people's needs. When people were going out in the local area or going on trips, more staff were on duty. Some people had been identified as requiring one to one support for various tasks such as accessing the community or displaying behaviours that challenged. The staff provided this level of support to make sure people were safe. Agency staff were used to cover when staff were sick or on annual leave. Regular agency staff were used when possible so that people who used the service were familiar with them. Staff carried out regular health and safety checks of the environment and equipment to make sure it was safe to use. These included ensuring that electrical and gas appliances were safe. Water temperatures were checked to make sure people were not at risk of getting scalded. Regular checks were carried out on the fire alarms and other fire equipment to make sure they were working properly. People had a personal emergency evacuation plan (PEEP) and staff and people were regularly involved in fire drills. A PEEP sets out the specific physical and communication requirements that each person has to ensure that they can be safely evacuated from the service in the event of an emergency. There was a service continuity plan in place which had been updated within the last month as it included the new operations manager who had come into post. There was clear guidance in place for staff to follow in the event of situations such as severe winter weather, a heat wave or a flu pandemic. It included contact details for staff and an alternative location for people to be moved to. There were also contact numbers for local emergency call out services such as gas and electric companies. There were environmental risk assessments in place for all areas of the service such as bathrooms and wet rooms, slips, trips and falls and a separate one for the annex and the car park. The risk assessments 7 Twyford House Inspection report 19 August 2016

8 identified specific risks which could occur and recorded control measures in place to reduce the risk. For example, to reduce the risk of a fall in the main building staff were required to clear up spills as soon as they were aware and put up signs to highlight where there was a spillage. Incident forms were completed when anyone was involved in an incident at the service. These were completed after any incident of behaviour that challenged. The forms were reviewed by the senior staff on shift who ensured that the appropriate action had been taken and determined whether any further action was needed, such as a referral to social services. If any marks or bruising had occurred, staff completed body maps to record where they were and the type of harm caused. Staff then conducted debriefs with the people involved and attached the records to the incident forms. The incident forms were then reviewed by the manager or deputy manager and then scanned onto the computer system and submitted to head office. If the incident related to a person's behaviour they were reviewed by the provider's behavioural therapist. The behavioural therapist said, "The quality of the incident forms here is noticeable. They give a lot more detail than other places. They look at what happens before an incident and after so we can often work out why something has happened and stop it from happening again. I think that should be commended." Staff supported people positively with their specific behaviours, which were recorded in their individual care plans. There was clear information to show staff what may trigger behaviour and staff were aware of the strategies to minimise any future occurrence. One person became distressed, moving between three staff members and displaying behaviours that challenged. Staff reacted quickly, offering the person reassurance and deescalated the situation immediately. This was in line with the strategies outlined in their care and support plan. Staff knew how to recognise and report different types of abuse. They had received safeguarding training and information about abuse. There was a 'see something, say something' poster on display in the office which detailed telephone numbers that staff could ring confidentially to report any issues without fear of discrimination. Staff told us they would report any concerns to the registered manager or use the whistleblowing line. Staff were confident that the registered manager would act on any concerns that were raised. The registered manager was aware of their safeguarding responsibilities. Referrals had been made to the local safeguarding authority when required and action had been taken to reduce the risks of them happening again. One relative told us they had been informed of a safeguarding incident that had occurred. They said that the staff had handled it really well and they had been very supportive. They said they felt staff had a good understanding of how to protect people and were confident that they did their best to prevent incidents from occurring. Relatives told us that medicines were managed well at the service. One relative said, "They're very good with giving him his medication. To be honest, I think they are better than the hospital was." There were appropriate arrangements in place for obtaining, recording, administering and disposing of prescribed medicines. Medicines were stored securely and at the correct temperature. People were supported to be as independent as possible when taking their medicines. Staff told us that one person always administered their own creams, and we saw this to be the case. Another person administered their own eye drops. People's medicines were stored securely, in individual safes in their rooms. Creams and liquids were dated when opened so staff knew how long they had been in use and if they were still safe for people to have. The registered manager carried out regular spot checks to ensure that medicines were being administered correctly. Medication Administration Records (MARs) were fully completed, showing people received their medicines as and when they needed it. Some people had medicines on an as and when basis (PRN) for anxiety and behaviours that challenged. There was guidance 8 Twyford House Inspection report 19 August 2016

9 in the medicine file on when these should be administered. One person's guidance stated, 'If anxious, ask them if they want to go out first.' Staff said they tried to distract people or talk to them and offer reassurance, before using medicines. There had only been two occasions when it was necessary to give the medicine in the past year. 9 Twyford House Inspection report 19 August 2016

10 Is the service effective? Our findings Staff were trained and supported to have the right skills, knowledge and qualifications to give people the right support. People were able to communicate with staff and make their needs known, even if they were unable to communicate verbally. Staff were knowledgeable about people's needs and followed guidance from a variety of health care professionals such as speech and language therapists (SALT) and occupational therapists (OT). A behavioural therapist said, "The staff team here is stable and they know people well. I'm always impressed with the way they deal with incidents." The registered manager arranged training for all staff through the provider's training department. Staff completed basic training such as first aid and safeguarding, and training in subjects related to people's needs, including behaviour management and MAPA. MAPA is a formal training programme where staff learn how to deal with aggression in a calm way, that keeps people safe. Some people displayed behaviours that challenged and staff told us they used the skills they learnt in MAPA training to keep people safe and calm. Appraisals were completed annually and gave staff the opportunity to reflect on their performance and set goals for improvement for the coming year. Staff were given feedback from their manager and where training and support needs were identified, plans were put in place with detailed information about how this would be achieved, such as additional training or shadowing other staff Staff received support during formal one to one meetings with their line manager. Several staff members had requested additional training in Makaton during these meetings. Makaton is a language programme using signs and symbols to help people communicate. The registered manager was arranging external Makaton training, and had worked with the local SALT team to ensure there was clear communication information in people's care files, so that staff were able to communicate effectively. There was also a board in a communal area showing basic Makaton signs. Staff communicated with people using Makaton throughout the day. New staff worked through induction training during a six month probation period, which included working alongside established staff. The provider had introduced the Care Certificate for new staff as part of their induction, which is an identified set of standards that social care workers work through based on their competency. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was 10 Twyford House Inspection report 19 August 2016

11 working within the principles of the MCA. Staff and the registered manager spoke with confidence about MCA and DoLS. One member of staff said, "Some people don't necessarily understand so they can't make difficult decisions themselves. They need guidance and support and if that doesn't work we have to have a best interests meeting. We make sure people are safe in the least restrictive manner." The registered manager had applied for DoLS for most people. The conditions on these DoLS, such as accessing external activities or moving to a more suitable part of the service had all been met. When people did not have capacity the registered manager had carried out capacity assessments. Best interest meetings had been held regarding people's health interventions and the support they needed to manage their behaviour. One person needed to have a bone density scan and the decision regarding this had been clearly documented. People were involved in the preparation of food and helped choose what they wanted to eat. There was a pictorial menu displayed in the dining room showing people what was for lunch and dinner. People discussed what they wanted to eat at regular residents meetings. Staff told us that they used pictures to encourage people to choose between different meals. The kitchen was open and people assisted with preparing and tidying up after each meal. Staff told us, "Some people, like [the person], help with washing and drying up. They love making cakes." On the day of the inspection the weather was hot and staff ensured that there was additional squash and water in the dining room so people could help themselves to different drinks throughout the day. People visibly enjoyed their lunch time meal and the atmosphere was relaxed, with people chatting to staff and each other. Some people had eating and drinking guidelines in place from SALT. Staff followed these guidelines and food and drinks were served at the correct consistency. People received the support and supervision they needed to eat safely. One person needed to eat small amounts regularly, due to their health needs. They requested chocolate ice cream mid morning and staff gave this to them immediately. Their relative told us, "Staff have been absolutely brilliant with the food issue and he has gained weight." Food and fluid charts and weight charts had been completed to monitor people who were at risk of malnutrition. People were supported to live healthy and full lives. People received support to manage a variety of health conditions, such as epilepsy. One relative said staff had worked with the GP and consultant to ensure their loved one's epilepsy was well controlled. There was detailed information in place for staff on different types of seizures, what they looked like and what action staff should take. Staff monitored when people had a seizure so they could provide information on any changes at people's medication reviews and hospital appointments. Staff assisted people to attend a variety of healthcare appointments and check-ups. One relative said, "They're very good about taking [my relative] to the doctor. Staff have supported them to go to the dentist and to the opticians." One person did not like going to the optometrist so staff had arranged for an eye care professional to come to the service instead, to ease their anxieties. The outcome of all appointments was recorded clearly and risk assessments and associated documents were updated regularly as a result. There was information in place for people to take with them if they were admitted to hospital. This laid out important information which healthcare staff should know, such as how to communicate with the person and what medicines they were taking. People had health action plans in place detailing their health needs and the support they needed. 11 Twyford House Inspection report 19 August 2016

12 Is the service caring? Our findings People spoke positively about the care they received and the kind and caring nature of staff. One person said, "I like living here, they are nice people." Relatives told us they were, "Extremely happy" with the care their loved one received and that, "The staff are very good, very caring and they will listen." Some people were unable to communicate verbally. Staff knew people well and there was detailed information in place to ensure they were able to anticipate people's needs and interpret their non verbal communication. One person's communication plan said, 'If I show you a cup or bowl it means I want something to eat and drink.' This person gave staff an empty cup and they were then shown two different jugs of squash. They were able to choose between them and then smiled as they drank their drink. Staff communicated with one person using Makaton, discussing the shower they had had earlier that morning and a keep fit class they had previously attended. Staff and the person understood each other well and were smiling throughout the conversation. One relative said, "The staff know my relative very well and are able to communicate with them even though they don't really communicate verbally. Staff know their moods". People personalised their rooms in line with their particular likes and preferences. Some people had decorated their rooms with pictures of things that were important to them such as family members or trips they had been on. One person invited us into their room and signed to staff that they wanted to move their bedroom furniture around. Staff said they needed to get someone to help them move it, and the person's furniture was then moved immediately. One person's care plan stated that they liked to have music playing in their room at all times. Their care plan directed staff to ensure their music system was plugged in and working or they would become distressed. This person took us by the hand and showed us to their room multiple times throughout the day. Each time their music was playing and they stood in their room looking visibly relaxed. Staff told us, "They know if you turn it off, even if they are down in the living room, it's so important to them, so we always make sure it is on." People were encouraged to be as independent as possible. One person required assistance to get dressed. Their care plan stated, '[The person] may hand you their socks back, this may indicate that they want to change them.' Staff said they always encouraged people to do as much as they could for themselves. People were encouraged to use advocacy services if they were needed. An advocate is someone who supports a person to make sure their views are heard and their rights upheld. Information was displayed about advocacy and the support it offered to people. The registered manager told us that two people were currently using an advocate to assist them to make important decisions about their lives. Staff protected people's privacy as much as possible. Staff knocked on people's doors and asked whether they could go in before entering. One person indicated that they needed more time as they were getting 12 Twyford House Inspection report 19 August 2016

13 dressed and staff told them that they would come back when they were ready. People were supported to stay in touch with their friends and relatives and visitors were always welcome at the service. One person was supported to stay in touch with their relative using internet technology on their personal tablet. Staff said this was good, as it meant even when the person's relative didn't visit they were still able to see them. People regularly stayed with their relatives at the weekend and went away on holiday with them. The registered manager told us they provided a monthly diary for one person's relative so they knew that they had been up to. Relatives we spoke to said they were always kept well informed about any changes to the health and welfare of their loved one. One relative said, "Staff take the time to chat to me when I am here, I appreciate that." People received the right care and support when their needs changed. The registered manager had recently changed the shift planner and handover documentation. There was now a detailed list of jobs which needed to be completed on each shift to ensure people received the care and support they needed. There was also space for staff to document what had happened to people on the shift before and if there was anything they needed to follow up on. Staff said they found this documentation much easier to use and they were now confident that things would not be missed. People's care plans and associated risk assessments were stored securely and locked away so that information was kept confidentially. When we asked questions about people staff answered in a quiet voice so not everyone was able to hear. 13 Twyford House Inspection report 19 August 2016

14 Is the service responsive? Our findings People received the care and support they needed and staff were responsive to their needs. People sometimes became anxious and staff responded quickly to reassure them and ensure they remained calm. Relatives said, "They have settled in here beautifully" and "They're very good at encouraging him to go out. He likes to watch people, that's his choice, but he's also been to the cinema and the dog track." People's needs were assessed before moving into the service, with as much involvement from people, their relatives, health professionals, and the person's funding authority as possible. The registered manager said that one person had moved in recently and they had visited them several times in hospital. From this information an individual care plan was developed to give staff the guidance and information they needed to look after the person in the way that suited them best. When a person was known to display behaviours that challenge the provider's behavioural therapist worked with staff and people to ensure a positive behaviour support plan was in place before they moved to the service. Staff continually updated people's care and support plans as they got to know people better. Detailed guidance was in place to ensure that staff were supporting people consistently to minimise their anxieties and any triggers for behaviours, such as a change in routine or unexpected noise. Staff made prompt referrals to mental health services and the provider's behavioural therapist if they required additional support. On the day of the inspection the provider's behavioural therapist was visiting one person because they became anxious when going out. Staff told us they wanted to make sure that the person was able to access the activities they wanted to, and had made the referral to help them to do so. Some people did not communicate verbally. Each person had their own, personalised communication passport in place, stating how they communicated and what staff needed to know about them. One person used Makaton to communicate and their passport had Makaton pictures throughout, so they understood what was in it. One person pointed at their picture on the front cover of their passport. They picked it up and started to look through it, pointing at other pictures of the things they liked to do. Staff said the person regularly did this, as they knew which passport was theirs and had helped choose the pictures that went in it. People received the care and support they needed, in the way they wanted. Preferences with regards to people's personal care and daily routine were documented in their care plan. Staff said this was helpful as when new staff started they knew how to provide people's care and support, even if the person was unable to tell them what they liked. One person's care plan said, 'I like a lot of bubbles in bath' and another person's said, 'I like to stay in the shower after I have had a wash as I like the water.' People's relatives told us that staff were good at accommodating people's requests for activities and were flexible on a daily basis if people didn't want to do the activities planned. People's relatives said that the service never pushed people if they didn't want to do anything and were responsive to people's moods. They said that people were able to choose what they did each day. 14 Twyford House Inspection report 19 August 2016

15 Staff had supported people to go on holiday to places such as centre parcs. Staff said that people who did not want to go away were planning day trips in line with their interests. People were taken out on a variety of day trips on the day of the inspection. One person went to the pub and another person went shopping. People were able to occupy their time however they chose, such as drawing or watching the television. Some people volunteered at the East Kent Railway Trust, a heritage railway project. The registered manager told us these people liked trains so it was the perfect job for them. Other people attended regular social groups and sensory sessions. The service had a complaints policy which staff were aware of and knew the process for. There was an easy read complaints procedure which was easier for people to understand. There were forms available for people to complete if they had any concerns or complaints to make. These were on pre-printed forms which were addressed to the provider's head office. The registered manager told us there had been four complaints in the last 12 months. Although these had been documented as complaints they had not been raised formally. The registered manager had recorded any concerns or areas for improvement as a complaint. Local investigations had taken place and been documented and face to face meetings had been arranged to discuss the issues and how to make things better. For example, a relative had raised a concern about the lock on their loved one's door. It was documented that the service had discussed this issue with them and then agreed how to manage the lock issue by removing it before trialling a different kind of lock. We saw that the lock had been removed from the person's door. There was no process in place for analysing complaints and identifying whether themes and trends were emerging. This was an area for improvement. Relatives of people who used the service told us that they would have no problem in making a complaint if they needed to however they had not needed to so far. They said they knew about the process and would always feel confident raising concerns with the staff. The service had received thank you cards and compliments from relatives of people who used the service. Comments included "Thank you for all your care and help you gave to [my relative]". 15 Twyford House Inspection report 19 August 2016

16 Is the service well-led? Our findings People regularly approached the registered manager throughout the inspection. They knew people well and offered support and guidance to staff. One member of staff said, "I think the management is really good, they have supported me on a personal level." A behavioural therapist said, "I am always very impressed with the registered manager, they look beyond the obvious and always analyse any incidents, I think they are very good." Relatives said there was good leadership at the service and that they found the manager approachable. One relative said, "It is a good home and I would recommend it." The registered manager worked alongside staff so they could observe and support them. Staff understood their roles and knew what was expected of them. Staff were supported by the registered manager who was skilled and experienced in providing person centred care. The registered manager knew people well and had worked with people with learning disabilities for over 20 years. Staff told us they felt well supported and felt comfortable asking the registered manager for help and advice when they needed it. The registered manager understood relevant legislation and the importance of keeping their skills and knowledge up to date. They were working towards a level five qualification in leadership and management in social care. The registered manager participated in a variety of events and forums with other managers that worked for the provider. The registered manager had notified the Care Quality Commission of important events as required. Documents and records were up to date and readily available and were stored securely There were links with the local and wider community and people had friends in the local area. The registered manager had organised an Easter party and had invited people from other services run by the provider to come and enjoy the day. People regularly visited local shops and cafes and staff said people were well known in the local area. There was a culture of openness and honesty; staff spoke with each other and with people in a respectful and kind way. Staff knew about the vision and values of the service which was based on equality and mutual respect. The registered manager told us, "The strength of this service is the flexibility with the underlying structure. We can plan and make sure people know what they're doing, but for the people we support things can change, their needs can change and we need to be able to adapt to that too." Staff meetings were held monthly at the service. Minutes demonstrated that staff were kept up to date with changes to the service and were also able to add their own agenda items and ask questions. Where actions had been identified as a result of audits, staff were made aware of any actions needed such as staff not signing support plans. People had detailed care plans, risk assessments and communication passports in place. Staff regularly updated these when people's needs changed to ensure that everyone received consistent care, regardless of who was supporting them. 16 Twyford House Inspection report 19 August 2016

17 The registered manager carried out monthly checks on the service. Quarterly audits were then carried out by the provider. We reviewed the quarterly audit book from April to June 2016 which was carried out by the registered manager and operations manager. This covered areas such as how staff interacted with people, whether people's health needs were monitored and acted on, whether relevant health and safety checks were carried out and whether the appropriate monitoring was in place. Areas for improvement were identified such as a person's key worker not being involved in the planning of their personal needs, monthly medication audit not being completed and a cleaning schedule not being available in the infection control folder. All actions had been completed at the time of the inspection. Annual service reviews were sent out annually to people who used the service, relatives, support staff and other stakeholders. Easy read surveys were given to people so they were able to understand them. The responses were used to formulate a quality development plan and included improvements such as new menus being developed and staff improving their awareness on the impact of people's behaviour on each other. Positive comments were received such as "The service is good" and "People receive good support". The registered manager received consistent support from the registered provider and the resources required to drive improvement were available. There was a strong emphasis on continually striving to improve. 17 Twyford House Inspection report 19 August 2016