Thornbury Community Services

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.This is the first assessment of the service. The key question has been rated outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 88 (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 demonstrated a proactive approach to assessing people’s needs before support began. Assessments were not only thorough and holistic but also highly personalised, reflecting each person’s background, communication preferences, strengths and long-term goals. Leaders gathered detailed information from people, their relatives, and met with a wide range of external professionals, including GPs, community nurses, and specialist teams.

People received comprehensive assessments which informed detailed, person-centred care plans. A recently implemented digital care planning system had been adapted to meet the needs of the service. Records were easy to navigate and contained detailed information about people’s medical histories, communication needs, family circumstances, allergies, religious beliefs and the support required to manage complex health needs. Risk assessments covered a range of areas, including environmental risks, medicines management, moving and handling, choking, aspiration, epilepsy and emergency situations. One relative told us “TCS worked with us to look at (person) needs and then created the care plan with our involvement.”

People’s communication needs were clearly set out within their care plans. Some people were not able to communicate verbally and where this was the case, guidance clearly set out how to communicate with the person. For example, some people used communication aids including picture exchange communication system (PECS), or Makaton. PECS allows people to communicate using pictures. Makaton is a language programme that combines signs (hand gestures), symbols (pictures), and speech to help people communicate.

The provider made sure people received effective care and treatment in line with current evidence, best practice and guidance.

People were supported by staff who had access to detailed clinical guidance for managing a range of complex health conditions. Specialist care plans contained step-by-step instructions, safety checks, escalation procedures and emergency protocols for areas such as tracheostomy care, ventilator management, oxygen therapy, suctioning procedures, epilepsy management, enteral feeding and central line care. Care documentation clearly set out goals, controls and actions for staff to follow, helping to promote consistent and safe care delivery in line with national clinical guidance.

The provider delivered evidence-based care and treatment for people with highly complex needs, enabling them to live safely in the community and reducing the likelihood of hospital admission. Support was informed by skilled multidisciplinary input and the application of recognised Positive Behaviour Support (PBS) principles.

PBS plans were developed using functional assessments to identify the underlying causes of behaviours of concern and guide proactive, person-centred interventions. Behavioural data was routinely analysed by clinical teams to monitor outcomes, evaluate the effectiveness of support strategies and inform ongoing care planning. This approach resulted in reductions in behaviours of concern, improved wellbeing and a decreased reliance on restrictive practices.

The provider demonstrated a strong organisational commitment to evidence-based practice through a dedicated PBS Lead, who oversaw the restrictive practice reduction strategy and PBS pathway. Trauma-informed care plans further ensured support was shaped by individuals' life experiences, needs and strengths.

The provider monitored staff competency to ensure care was delivered safely. Staff received role-specific and complex care training, competency assessments and ongoing supervision. Staff were sufficiently trained to carry out their roles and the service had systems to ensure staff training was refreshed regularly.

People were also supported to achieve personal goals through positive risk-taking approaches, enabling greater independence, community participation and improved quality of life while maintaining their safety.

The provider worked effectively with people, staff, teams and partner organisations to plan and deliver joined-up care.

Care planning demonstrated partnership working with families and external professionals. Records showed the service worked closely with respiratory teams, consultants, neurology services, integrated care boards, health visitors and other professionals involved in people’s care. Staff shared information appropriately and escalated concerns when people’s needs changed. One staff member told us, “We attend multi-disciplinary team meetings and have regular communication with the client’s health professionals to keep up to date with the clients health conditions.”

The service had clear arrangements to support communication and collaborative working. Staff had access to clinical leads, partnership managers, duty clinicians and out-of-hours support. The service held regular meetings, daily huddles and supervision sessions to share learning and coordinate care. Inspection feedback confirmed the service worked with health and social care professionals and coordinated admissions and discharges to support continuity of care. One relative told us that “the clinical lead attended meetings with them and raised any concerns.

The provider demonstrated a strong commitment to positive risk-taking, enabling people to pursue meaningful interests, increase independence and participate more fully in their communities. For example, one individual with a history of incidents at bus depots was supported through collaborative planning with depot management and agreed risk-reduction measures. As a result, they were able to safely access an activity that was important to them, enhancing their quality of life while risks were managed proportionately.

Staff worked closely with occupational therapists and clinical teams to reduce restrictive practices for people who had previously required higher levels of physical intervention. By introducing personalised sensory strategies, people were better able to regulate their sensory needs, resulting in improved wellbeing, greater autonomy and a reduction in the use of restrictive interventions.

The provider also maintained a proactive, multidisciplinary approach to risk management, sharing monthly reports with professionals to support collaborative decision-making. This ensured people could benefit from positive risk-taking opportunities that promoted choice, independence and improved outcomes while maintaining their safety.

The provider supported people to maintain their health and wellbeing and access healthcare services when they needed them.People had care plans that promoted good health outcomes and reflected their individual health needs. Records included monitoring arrangements, health appointments, nutritional support, physiotherapy programmes, respiratory care and specialist clinical interventions. Staff monitored people’s wellbeing, recognised changes in health and sought support from relevant healthcare professionals when required.

The provider encouraged coordinated healthcare support. Care plans contained information about hospital admissions, ongoing treatment and specialist input to help ensure people received appropriate care. Inspection feedback confirmed health changes were identified and escalated appropriately, and that people’s health and wellbeing needs were reviewed regularly.

The provider supported people to achieve better health outcomes through proactive clinical oversight and personalised healthcare planning. All people with autism and/or a learning disability had a Health Passport and Health Action Plan in place, with regular clinical reviews undertaken in line with assessed risks. The provider's clinical governance framework ensured reviews were completed at appropriate intervals and triggered promptly following significant incidents, safeguarding concerns, changes in need, hospital admissions, complaints, or increased risks.

Evidence demonstrated a risk-based approach to clinical support, with higher-risk individuals receiving enhanced oversight. Positive Behaviour Support (PBS) plans also incorporated physical health needs, recognising that unmet health needs, including pain and other health issues, could contribute to behaviours of concern. This supported the early identification of health concerns and enabled people to access timely, coordinated care to maintain and improve their wellbeing.

The provider monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The provider had systems to monitor care quality, staff performance and service outcomes. Governance systems included audits, quality assurance processes, incident reviews, complaints monitoring, competency assessments and tracking systems for training, supervision and care plan reviews. Care records and risk assessments were reviewed at regular intervals, and electronic systems alerted managers when reviews were due.Learning was embedded through incident review processes and oversight arrangements.

A person with complex healthcare needs, including 24-hour ventilation via a tracheostomy, was supported to maintain a high quality of life and remain living at home. Consistent support enabled them to access hydrotherapy, attend daily outings, participate in family events and take holidays. This demonstrated how people were supported to achieve positive outcomes and lead fulfilling lives in line with their preferences and goals, despite the complexity of their needs.

The provider made sure people were involved in decisions about their care and support and that consent was sought in line with legislation and guidance. People’s capacity had been assessed and documented within care plans to inform staff. Care plans contained reminders for staff to seek consent when carrying out care. People and their relatives told us that their loved ones were given choices and their right to decline was understood and respected by staff. Relatives told us, “He’s given a choice of meal, clothes and the activities he does.”

Care records reflected people’s wishes, preferences and involvement in decision-making. Where people lacked capacity to make specific decisions, the provider followed the principles of the Mental Capacity Act and documented decisions appropriately. Records included mental capacity assessments, best-interest decision-making and applications relating to deprivation of liberty safeguards where required.

Governance processes confirmed consent and capacity were recorded, and Mental Capacity Act documentation demonstrated the appropriate application of the legislation. Care plans reflected assessed needs, risks and the choices people made about their care and treatment.