CQC report explained · a residential care home
What the CQC found at 42 Twyford Gardens
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2022
Requires Improvement; inspectors found serious safety, staffing, dignity and leadership problems, with multiple legal breaches.
The unannounced inspection visit took place on 8 September 2022. Inspectors reviewed care and medicine records, staff training and management records. They spoke with people, relatives, staff and health and social care professionals, and observed care.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found unsafe medicine management, incomplete risk assessments, missed opportunities to learn from incidents, gaps in safeguarding, and staff who had not always received the training or support they needed.
People were not always treated with dignity, involved in decisions or supported to follow their interests. The home did have strengths, including good infection control, clean premises and some suitable environmental features. However, the overall rating means there was limited assurance about safety and an increased risk that people could be harmed.
The previous rating was Good, published in March 2018. The provider was asked for an action plan and said it would provide resources and make improvements. CQC said it would monitor progress with the provider and local authority.
Infection control
Inspectors were assured that the home had suitable arrangements to prevent and manage infections, including safe use of protective equipment and visits.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Clean environment
The home was described as clean and hygienic.
“The service was clean and hygienic.” from the report
Suitable facilities
People had their own bedrooms and bathrooms. The home also had ramps, wide doorways and track hoists to support movement and transfers.
“There were wide doorways and ramps to the front and back doors to help people move around the home freely.” from the report
Some health support
There were examples of staff making quick health referrals when people became unwell. Care passports were also available to share medical information.
“We saw examples where staff had supported some people to make referrals to health care professionals quickly where people had become unwell.” from the report
Medicine safety
seriousMedicine records were not accurate or consistent. There had been repeated errors and medicines had sometimes run out, meaning people did not receive them as intended.
“There had been multiple administration errors occurring consistently since May 2022 meaning people had not received medicines as intended due to staff error.” from the report
Risk of harm
seriousChoking and constipation risks were not always assessed or managed safely. Some staff were not trained to use the available choking equipment.
“One agency and one permanent member of staff we spoke with had not been trained to use equipment available in the service to support people to dislodge food if they choked.” from the report
Safeguarding
seriousSome staff did not know how to report suspected abuse. Allegations involving staff had not always been recognised or reported.
“These incidents had not been recognised as potential abuse or reported internally or externally by the provider.” from the report
Staff training and numbers
needs fixingVacancies were being covered with agency staff, and staff said they did not always receive enough training, supervision or competency checks. People sometimes had to wait for personal care or missed one-to-one time.
“There were not always enough trained staff to administer medicines or take people out for their allocated 1:1 hours.” from the report
Dignity and choice
seriousPeople were not always spoken to respectfully or given suitable choices. Inspectors observed disrespectful language and heard that some staff made decisions for people.
“People were not always supported in an inclusive or respectful way, offered choices or involved in their care.” from the report
Activities and personal goals
needs fixingPeople were not consistently supported to follow interests, go out or work towards aspirations. One person spent the whole inspection day without being offered an activity beyond television, food or drinks.
“People were not being supported to regularly identify, or review, on-going individual aspirations and life goals, affecting their overall quality of life.” from the report
- 01What has changed since the inspection to prevent missed medicines, administration errors and medicines running out?
- 02How are choking, constipation and other health risks now assessed, recorded, monitored and reviewed?
- 03How do you ensure every permanent and agency staff member has the right induction, training, supervision and competency checks before supporting people?
- 04How will you make sure people are involved in their care plans, offered suitable activities and supported to follow their interests and goals?
- 05Who is currently responsible for managing the home, and how are safeguarding concerns, complaints and communication with relatives handled?
This inspection looked at all five key questions, including infection prevention and control, and the ratings for all five questions changed from Good at the previous inspection to Requires Improvement. This explanation was written from the published report of 4 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 42 Twyford Gardens
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2020
Registered with the Care Quality Commission on 1 December 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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28 live-in carers within about an hour of West Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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