42 Twyford Gardens

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires improvement. At this assessment the rating has remained Requires improvement. This meant people’s needs were not always met.

The provider was previously in breach of the legal regulation in relation to good governance. Whilst some improvements had been made at this assessment the provider remained in breach of this regulation.

For example, people’s care records being up to date and accurate and information oversite of people's assessments.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The staff demonstrated a positive open culture within the team providing direct support. Senior leaders embraced feedback about the challenges they faced. Staff said, “when I have raised concerns with the area manager, she listened to me and helped.” Managers had supervised the staff team and held team meetings which provided shared goals to be focused on relating to the outcomes of people being supported. When speaking about the culture of the service staff said, “I think it’s really nice and happy here, we are all from different areas of the world, we have different beliefs and strengths, we respect each other and celebrate as a team.” Another staff member said, “Staff are kind and speak to each other and people in a respectable way.”

Not all leaders understood the context in which the service delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience, and credibility to lead effectively, or they did not always do so with integrity, openness, and honesty.

The providers processes had not effectively measured the skills and competence of leaders and as a result, had failed to ensure they received support to lead effectively, this resulted in the staff team receiving limited guidance and support. An inadequate assessment for a new person, with lack of oversite from the provider caused safeguarding concerns and impact on others living at the service. We observed the manager’s practice did not demonstrate they had the skills, knowledge and experience to support positive behavioural approaches to meet the needs of people. We shared our concerns and feedback with senior management who promptly took steps to strengthen the leadership in the service which included, oversite from an interim manager to support the staff following the first day of our assessment on 29 October 2025.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they were able to raise concerns with good knowledge around the policies and procedures were in place to support them including a whistle blowing policy, staff also explained they could share ideas with leaders and felt they would be listened too. One staff member said, “Yes they would listen to me, and I would raise concerns if I had them.” Another staff member said, “I am aware of how to raise concerns and am confident to do this if I need to, I believe the manager and senior manager would listen if I raised a concern.” Staff also explained how their feedback during staff meetings can contribute towards peoples care planning documents.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The staff team were from a variety of cultures who worked together collaboratively, focusing on each other's strengths and supported each other as a team. Staff said they felt respected in their roles and they were stronger as a team due to their diversity.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The providers quality assurance process did not adequately ensure peoples care plans were accurately reviewed, updated and documents fully reflected peoples current care and support needs. Finance records were not adequately reviewed so they matched the providers finance policies. Auditing processes had not identified all risk assessments were up to date, as an example pressure risk assessments did not always reflect a person’s current needs. This had continued throughout the inspection process with documents submitted following review that still contained information that was not an accurate reflection of people’s current support needs. Senior management had not identified shortfalls in the assessment process to admit new people before it had been completed, and the person moved into the service. This led to a significant impact on the person which we observed during our assessment. A senior manager at the assessment told us they were introducing a manager peer review audit across the area.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff openly worked with other health care partners sharing information promptly and transparently when needed. For example, when the staff was struggling to support a person, they contacted the relevant health and social care partners communicating their concerns for the persons wellbeing and their ability to support them safely and arranged meetings to discuss how to proceed with the persons wellbeing at the forefront of these discussions.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had not fully embraced the current best practice guidance right support, right care, right culture. Leaders had not always been collaborating with people, and staff to build a culture that focused on enabling people to enjoy a full life. People’s initial assessments of their needs heighted specific conditions and support requirements, which were not always explored and fully understood before they moved into the service, possibly contributing towards the staff’s ability to support their wellbeing, for example we observed staff struggling to support a person in periods of distress. Following our assessment, the provider changed some of its practices to improve people’s assessment process by adding extra oversite providing better outcomes and reducing impact on people. Leaders had responded proactively to an environmental health inspection by creating an action plan to improve their rating.