The Care Quality Commission
  • Care Home
  • Care home

42 Twyford Gardens

Overall: Requires improvement read more about inspection ratings

42 Twyford Gardens, Worthing, West Sussex, BN13 2NT (01903) 263906

Provided and run by:
Achieve Together Limited

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

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.

8 September 2022

During an inspection looking at part of the service

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

42 Twyford Gardens is a residential care home providing personal care to three people, one of whom was in hospital at the time of the inspection. The service can support up to four people. The service was a detached bungalow with a garden, near to the town. People had their own bedrooms and bathrooms. There were shared eating and living areas.

People’s experience of using this service and what we found

Right Support:

Risks to people were not always assessed, monitored and managed safely. Systems in place did not always protect people from abuse and improper treatment. People’s medicine support was not being managed safely. People were not always supported to assess their needs effectively and did not always achieve good outcomes from their support. Staff had not always received effective training or supervision. The service was clean and hygienic.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care:

Staff did not always communicate or support people in dignified or respectful ways. Improvements were needed to make sure people were involved and included in a personalised way when being supported by staff. People told us staff were not always caring and did not always encourage them to be as independent as possible. Professionals who worked with staff and relatives of people at the service gave us mixed feedback about the quality and safety of the support people received.

Right Culture:

Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. Internal quality assurance systems and processes to audit or review service performance and the safety and quality of care were not operating effectively to identify or resolve issues.

People and their relatives said they did not always feel involved and engaged in planning their support or developing the service. Staff did not always feel supported to fulfil their roles and responsibilities. Staff and people told us the culture of the service was negative and was not helping people to achieve good outcomes.

The provider was aware of quality and safety issues at the service. They had offered assurances about actions they would take and were committed to providing resources to make any necessary improvements as quickly as possible.

The provider had an Equality and Diversity Policy and the interim manager told us how it was important to them that they always promoted and respected staff equality and diversity as a leader within the provider’s organisation.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 9 March 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 42 Twyford Gardens on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified multiple breaches of regulations at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.