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Quality Assurance

We are committed to providing ethically driven outstanding care.

In order to do this we need to continually assess our standards, gathering information from many sources, and providing a feedback system that allows recommendations and improvements to occur. We understand that in order to improve quality, we need to listen, learn and respond.

Our Quality Assurance system includes regular audit, internal and external inspection and information feedback, and an annual quality and safety report that informs the business and service development plan.

Our Quality and Safety Assurance

In addition to our own internal feedback surveys from various stakeholders, we have a very experienced external Consultant who provides feedback from professionals. We also have a very experienced Expert by Experience to feedback views from families and relatives.

In 2016 we implemented an anonymous external staff survey, and this will be completed annually and then fed back to managers and staff in terms of improvements we can make.

Inspections and Service Improvement

Each service receives an unannounced internal mock inspection from a senior manager each year. These inspections are measured against the CQC standards and regulations, and action plans are generated for managers to complete. In addition, we are regularly inspected by the CQC, and also the Local Authority, and any necessary improvements are completed.

We are keen to continually assess quality as well as capture more detailed information annually, and therefore members of the senior management team regularly monitor each service during informal visits to services. Information about culture and any concerns raised are recorded in writing. These are audited annually.

We have a transparent complaints procedure that is audited regularly with any improvements made where necessary.

Providing care in line with the Care Quality Commission

We aim to ensure that we meet individual’s needs by providing safe, effective, caring, responsive, and well led care in line with the five Key Questions set out by the Care Quality Commission. We do this in the following ways:

How is our service SAFE?

  • Regular audits in operational, HR and Health and Safety.
  • External Consultant and Expert by Experience involved in providing feedback from stakeholders.
  • On-call provision around the clock.
  • Feedback (satisfaction surveys, complaints and compliments) from the individuals who use the service, family, professionals and staff.
  • Health and Safety Compliance Manager for the company to ensure all health and safety legal requirements satisfied.
  • Safeguarding policies incorporating the multi-agency policy and also the local procedures relevant for that authority.
  • Regular Safeguarding, Mental Capacity Act, DoLs,Human Rights Act and whistle-blowing training for all staff.
  • Paid, two week classroom induction training,  that includes BILD approved PBMpro training, and training by healthcare professionals such as psychologists and our Learning Disability Nurse.
  • All staff recruited using process of DBS checks with no staff working in services before checks are completed and approved.
  • Staff recruited with the aim of finding staff who have not only some experience in working with or caring for people with intellectual/learning disability but also the right attributes, attitudes and values.
  • Compatibility assessments for not only staff but also individuals who use the service.
  • External consultancy for all HR.
  • Paid period of shadowing, and assessment of competencies for all new staff to ensure social coaching, modelling and ongoing assessment.
  • Regular reviews of positive behaviour support plans, and risk management plans in partnership with the individual, their family, the purchasers, the agencies involved, and the clinical team including the key workers and care support staff.
  • Working in partnership with external local agencies to provide wrap around services and a good understanding of risk and contingency management.
  • Capacity assessments and best interest decision making for those individuals who lack capacity to agree to arrangements for their care or treatment.

How is our service EFFECTIVE?

  • Outcomes are assessed using empirically driven measures.
  • Outstanding staff training including delivered by skilled professionals on a broad range of topics including BTEC diploma in PBM.
  • On-site coaching from trained professionals to ensure the driving up of quality.
  • Regular supervision and appraisals for staff which can identify training needs and personal development opportunities.
  • Regular reviews of positive behaviour support and risk management plans.
  • Trained Best Interest assessor who is part of the senior management team.
  • Health Action Planning for each individual which is regularly reviewed.
  • Ability to provide coaching and support for staff in behavioural management and pro-active planning. 
  • Mock inspections carried out by senior management.

How is our service CARING?

  • Person centred care promoted through training and adopting PBS as a framework. PBS seeks to understand the context and meaning of behaviour in order to inform the development of supportive environments and skills that can enhance a person’s quality of life.
  • Developing a true understanding of the person, through communication and developing appropriate relationships.
  • Involving the individual in every aspect of their care through reviews, care support planning, house meetings, satisfaction surveys and complaints/compliment policy.
  • Looking at compatibility of environment, staffing and risk profiles with every new referral.
  • Advocacy services promoted and encouraged where necessary.
  • Privacy and dignity promoted through dignity champions in each unit.
  • Privacy and security enhanced through personal alarm/cctv/intercom systems where appropriate.
  • Staff recruited on basis of aptitude (including experience and qualifications), attributes and attitudes, and use of shadow shifts to assess competence.
  • Supervision, appraisals and de-briefings that identify attributions and culture shift in staff teams.
  • Pro-social modelling to encourage positive attributes and transparent care.
  • Work-Life balance for staff with every other weekend guaranteed off.
  • Internal promotion system and trainee manager training available.
  • Specific training for Team Leaders and Managers.
  • Development of a Reduction in Restrictive Practice Plan

How is our service RESPONSIVE?

  • All care planned according to the individual’s choices and needs taking into account positive risk taking and least restrictive principles.
  • Use of Positive Behaviour Support throughout the company to guide the care practice. This uses person-centred, values-based approaches to ensure people are living the best life possible.
  • Environments that suit the individual including the option of communal and self-contained provision. Getting the environment right is essential to good outcomes.
  • Comprehensive assessment, transition, placement and move on policy.
  • We understand that as well as static risk, there are also dynamic risk factors and these are likely to change over time. Therefore we review risk regularly from the moment of referral through to the discharge process, being responsive to the changes that may occur during the individual’s journey with us.
  • Changes in risk shared as appropriate with external multi-professional teams and contingency plans discussed and in place.
  • Risks and needs are reviewed regularly against the principle of least restrictive practice which we evidence in positive behaviour support plans, clinical meetings, and reviews.
  • Annual satisfaction surveys for staff, individuals, families and professionals with anonymous results published on the website.
  • Complaints and Compliments policy available to all who use the service.


How is our service WELL LED?

  • The two directors of CTS are both experienced Consultant Clinical Psychologists and as such they hold professional conduct as vital to the core of their provision.
  • Fit persons test for all of the Senior Management.
  • The Clinical Team includes professionals from many backgrounds such as Nursing and Psychology .This team provides the therapeutic guidance and coaching within a PBS framework that enables staff to pro-actively engage with individuals daily. The aim of this is to enhance life skills and inclusion for all individuals who use our services.
  • Training for staff is delivered to excellent standard which includes not just the mandatory requirements but also more specific training in PBMpro, PBS, Autism, Mental Health, Emotional Regulation Problems, Boundaries, Social Coaching and Pro-social modelling.
  • There is a wide and supportive network of support provided to all our services which ensure excellent standards in care are achieved. This compliments the support network that is there to provide care to the service user.
  • We train all managers and team leaders in how to develop leadership skills in the workforce and we promote and develop staff wherever possible.
  • Partnership working which includes working with external local agencies such as MAPPA, Safeguarding, CLDTs, GPs,  CQC and Local Authorities in order to drive up quality and provide cohesive, transparent, and consistent care. We work alongside these agencies with a shared understanding of risk, expectations of outcomes, and clear contingency plans.
  • We work with other providers to share good practice.
  • Memberships to our own professional bodies in order to maintain our knowledge base and ability to practice.
  • Networked with provider support and other organisations to ensure the sharing of knowledge, good practice and quality.