Updated 28 October 2025
42 Twyford Gardens is a care home providing accommodation and personal care to people with a learning disability, mental health conditions and autistic people.
We conducted an assessment which included two onsite visits 29 October 2025 and 3 November 2025 alongside the provider sending us information until the 6 November 2025.
This was a comprehensive assessment and was conducted due to the services previous rating of requires improvement and to follow up on the previous breaches of regulations.
The provider was previously in breach of the legal regulation in relation to governance. Whilst some improvements had been made at this assessment they remained in breach of this regulation.
The provider did not have clear systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. Auditing systems had failed to identify shortfalls.
The assessment process in operation was not effectively mitigating risk for a person resulting in significant impact for both them and others living in the service. Staffing levels had not been reviewed following a new person moving in. Care planning documents did not always reflect people’s current needs. Specific information was not always considered when creating support plans. Policies in relation to people’s finances were not always followed. Risk assessments were inconsistent and did not always consider peoples specific needs around support when people experienced periods of distress.
There were some shortfalls with senior staff understanding their responsibilities to support speaking up, following our feedback the provider took immediate action to resolve this. Care management processes were not always monitored effectively to ensure leaders and staff always had the skills, guidance to support people safely.
Staff demonstrated a strong knowledge of people’s rights to make choices, understanding the principles of the Mental Capacity Act (MCA) 2005 and promoting independence. People told us they were supported by kind staff who respected them and their choices.
There were improvements with medicines processes, and the provider was no longer in breach of safe care and treatment. The service continued to embed these improvements.
Managers had created a positive culture in the service in which the staff provided support to people in a friendly caring manner and treated the people they support with respect and dignity.
The provider was previously in breach of the legal regulations in relation to person centred care, dignity and respect, need for consent, staffing and safeguarding service users from abuse and improper treatment. At this assessment improvements have been made, and the provider was no longer in breach of these regulations.
We have assessed the service against ‘Right support, right care, right culture’ (RS,RC,RC) guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found people were mostly being supported in line with this guidance but there were some barriers around good access to local communities' people were experiencing which the service was working on resolving.