Beyond Limits (Plymouth)

On this page

• 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

Effective – 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.

At our last assessment we rated this key question Good. At this assessment the rating has changed to 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 100 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

Assessments were comprehensive, accurate and reflected each person’s unique circumstances, strengths, preferences and desired outcomes.

The provider used a thorough and highly personalised assessment process to ensure support was effective and focused on what mattered most to each person. Before support began, a bespoke Service Design Day was held with the person, their family and others who knew them well. This process explored the person's life history, strengths, talents, interests, hopes and aspirations, ensuring they were seen as an individual rather than being defined by their diagnosis or behaviours.

Detailed life story work formed a key part of the assessment process. By working closely with families and those important to the person, staff gained a thorough understanding of their life experiences, including what had been positive and what challenges they had faced. This provided valuable insight into the person's needs, preferences, strengths and motivations, enabling the service to develop highly personalised support that reflected their goals and promoted positive outcomes.

Discussions also explored what an ideal home environment and support team would look like, including how the person and their family wished to be involved in recruiting staff. Information gathered throughout the assessment was used to develop a personalised Service Design, which informed detailed Working Policies (care plans). These documents clearly reflected the person's preferences and provided staff with comprehensive guidance on promoting wellbeing, maintaining safety and supporting positive risk-taking in a person-centred way.

The Working Policy for one person, who had lived in institutional settings for many years before moving into their own home in the community, highlighted the importance of ensuring they felt safe, secure and supported by a consistent staff team. Over time, the person's world had become increasingly limited, and a key part of their transition home was supporting them to reconnect, at their own pace, with activities and experiences they enjoyed. This now included coastal and moorland walks, drives to visit and look out at the sea, regular meals out, spending time with family, baking and taking part in household tasks. The Working Policy was clear that support needed to be carefully balanced with helping the person manage intrusive thoughts and intense emotions. It was essential that staff had a clear understanding of the person's individual communication needs and were ‘confident, calm and fun’ communicators who could build trusting and supportive relationships.

Working policies and safety assessments were regularly reviewed and updated to reflect changing needs, while people remained actively involved in decisions about their care, support and future goals. This approach enabled staff to understand people well, manage risks positively, promote independence and deliver highly individualised care.

The provider consistently planned and delivered care and treatment in partnership with people, which ensured support was centred around what was important to them and what mattered most in their daily lives. Care was delivered in line with current legislation, best practice guidance and evidence-based approaches, while remaining flexible and responsive to each person’s individual needs, preferences and goals.

The service demonstrated a strong culture of continuous learning and innovation, working proactively with specialist healthcare services to improve outcomes and reduce avoidable risks for people. Staff developed effective partnerships with families, clinicians and external professionals to ensure people's complex health needs were understood and managed consistently in line with best practice. A notable example was the development of a bespoke clinical protocol for a person with complex epilepsy who experienced frequent hospital admissions. The service worked collaboratively with the person's family and the local emergency department to design an agreed approach to treatment, ensuring healthcare professionals had clear guidance on the person's needs and the most appropriate interventions. This resulted in more timely, personalised care and reduced the likelihood of unnecessary delays in treatment. A relative described the significant impact of this approach, explaining, "Otherwise [person's name] will sometimes be left 8 or 9 hours in AE when it's not necessary." They also praised the expertise of the staff team, telling us, "Their staff team are so well trained on medical needs. Our big aim was to get a protocol in place everyone can follow. Our advice to AE doctors will be what's best." This demonstrated the provider's commitment to partnership working, innovation and achieving better health outcomes through person-centred solutions.

The provider demonstrated an exceptional commitment to partnership working across staff teams, healthcare professionals and external organisations to achieve the best possible outcomes for people. Collaborative working was embedded throughout the service, which ensured people experienced coordinated, seamless care that reflected their individual needs, preferences and aspirations.

Some people supported by the service had experienced significant trauma, had complex needs and, at times, communicated their distress through their behaviour. Despite these challenges, the provider demonstrated an unwavering commitment to people, adopting a culture of perseverance and person-centred care. The registered manager told us, “We have never served notice on anybody no matter how difficult it got. This is our guarantee to families. We will never give up. We value the person.” This ethos was reflected in the way the service worked collaboratively with families, health professionals and specialist agencies to manage risks and maintain placements, even during periods of increased need or deteriorating mental health. The provider recognised that complex decisions about risk should not be made in isolation and promoted a shared approach to decision-making, ensuring responsibility was jointly owned by all relevant parties. The registered manager explained, “When there are big and difficult decisions about risk taking, we make sure it’s a shared responsibility.” This approach helped ensure risks were managed effectively while continuing to uphold people's rights, choices and opportunities to live fulfilling lives.

People experienced continuity of care through small, consistent staff teams who were carefully matched to them based on their personalities, skills, interests and individual preferences. People and their families were actively involved in selecting staff, helping to ensure positive and meaningful relationships were developed from the outset. Relatives told us new staff completed a thorough induction and spent time shadowing experienced team members, who provided coaching and mentoring to help them develop a detailed understanding of the person's communication, support needs, preferences and routines. This approach helped ensure care was delivered consistently, promoted positive outcomes and enabled people to build trusting relationships with staff who knew them well.

The provider demonstrated an exceptional commitment to support people to live healthier lives and achieve outcomes that had a significant and lasting impact on their wellbeing, independence and quality of life.

Staff worked in partnership with people, families and healthcare professionals to overcome barriers to accessing appropriate healthcare and advocated to ensure people received the treatment and support they needed. People were actively supported to manage their health and wellbeing, including attending medical appointments and accessing input from a range of multi-disciplinary professionals. Hospital passports were in place to ensure health staff had the information they needed to provide safe, personalised care.

The provider recognised that people with disabilities could experience health inequalities due to factors such as communication barriers, diagnostic overshadowing and unconscious bias, and took a proactive approach to challenging these inequalities and promoting equitable access to healthcare. This commitment resulted in significant improvements to people's lives. For example, one person who was unable to communicate verbally had undergone 2 unsuccessful operations to treat a health condition and was advised that no further treatment options were available. The service, alongside the person's family, continued to advocate on their behalf over several years and successfully obtained a further specialist review. As a result, a third operation was agreed and ultimately resolved the condition. Healthcare professionals were reassured by the provider's ability to deliver the aftercare required, which contributed to the decision for treatment to proceed.

Another person experienced frequent seizures that were not fully controlled through medication. Although an alternative treatment was available, the person initially declined due to anxieties about the procedure. Staff worked closely with the person, their family and specialist healthcare professionals to provide reassurance, information and emotional support, enabling the person to make an informed decision about their care. Through this collaborative approach, the person was able to access treatment that had the potential to significantly improve their health outcomes and quality of life.

The provider demonstrated an outstanding commitment to monitoring, reviewing and improving outcomes for people. Systems were highly personalised and ensured care and treatment continually evolved to meet people's changing needs, preferences and aspirations. The provider did not measure success solely against clinical expectations; they actively sought to understand what a positive outcome looked like for each individual, and ensured their views remained central to decision-making.

A key strength of the service was its highly personalised annual bespoke planning day, which was designed around each person’s individual preferences, interests and communication needs. People chose who attended, where the event took place and, in some cases, the theme for the day. The planning day was an opportunity to celebrate achievements, reflect on progress and identify aspirations for the future. One person told us their achievements included babysitting and taking part in activities at the provider’s head office. They explained their next goal was to travel abroad and swim with dolphins, adding, “They are really kind and help me. They work fantastically with me.”

The provider recognised meaningful involvement looked different for different people. Where appropriate, planning days explored what was working well and what could be improved. However, where such discussions may cause distress or anxiety, the provider adapted their approach, completing reflective reviews separately while still ensuring learning was captured and support strategies were reviewed. People who preferred not to participate in a formal planning event were offered alternative ways to share their views, for example, informal conversations over a meal with family and staff, or views and observations gathered over the year. For people who were unable to communicate verbally, staff worked closely with family members and reflected on their observations of what contributed to the person's happiness, wellbeing and quality of life.

Outcomes and aspirations were recorded within personalised presentations, often using photographs and accessible formats, and incorporated into people's Service Designs to inform future support. This approach created a continuous cycle of review, reflection and improvement that helped ensure support remained relevant, person-centred and focused on achieving outcomes that mattered to people. The registered manager described the ethos of the service, saying, “It is important to recognise that the size of a goal matters less than its personal significance. Small and large goals are equally valuable when they contribute to meaningful progress.”

The provider demonstrated an exceptional commitment to ensuring people’s rights around consent were understood, promoted and consistently respected. Consent was embedded within the culture of the service and staff viewed it as an ongoing process rather than a one-off event. People were supported to make decisions about their care, treatment and daily lives in ways that maximised their independence, choice and control.

Staff understood the importance of promoting choice, control and independence, recognising that people should be at the centre of decision making. They spoke positively about people's rights and were committed to ensuring they maintained as much control as possible over their day-to-day lives and future aspirations. One member of staff described having previously supported a person who had decided they no longer wanted them to be part of their support team. They explained, “The person you work with has the right to say they don’t want to work with you anymore. They really are at the centre of decisions.” This demonstrated a culture in which people were empowered to express their views and preferences and were actively involved in decisions about their support, including who provided it. The service recognised and respected people's right to make these choices, ensuring they remained at the heart of decision-making processes.

Some people had spent many years in institutional care and were not accustomed to being offered choice or asked for their consent. The service supported people to develop trusting relationships with staff, helping them to understand their rights, increase their independence and build confidence in making decisions about their own lives. The registered manager explained, “A lot of people are so institutionalised. They will come in and ask if they can have a cup of tea, or don’t understand they don’t need to go to their bedroom if they are feeling anxious. We tell them, ‘This is your home. The staff will go to the guest room if you need space.”

The provider ensured staff had a detailed understanding of people's individual communication needs, enabling information to be shared in ways that were meaningful and accessible to them. This supported people to understand the options available and make informed decisions. For example, one member of staff described how a person they supported had their own unique language and vocabulary and preferred to communicate through stories. Staff had developed a strong understanding of this communication style, enabling the person to effectively express their needs, wishes and preferences, make choices about how they spent their time, and decide who they wanted to see.

The provider demonstrated a strong commitment to the principles of the Mental Capacity Act and ensured restrictions on people's rights were minimised. Where people lacked capacity to make specific decisions, the management team ensured robust and decision-specific mental capacity assessments were in place. Any restrictions implemented to keep people safe, such as the use of assistive technology, were considered carefully and were only introduced following appropriate legal authorisation. Records showed decisions were made in people’s best interests and, where required, were authorised through the Court of Protection. This helped to ensure people's rights were protected and that restrictive practices were lawful, proportionate and the least restrictive option available.