CQC report

The Care Quality Commission (CQC) has inspected and rated Thornbury Community Services (TCS) as an ‘Outstanding’ healthcare provider.


Our Managing Director, Emrys, would like to say thank you to everyone involved in the collaborative effort to achieve an outstanding rating and being a part of our journey to deliver world-class care to our clients in the community.

Less than 2% of health and social care providers inspected receive an ‘Outstanding’ rating, which truly highlights the continued commitment of our teams delivering exceptional person-centred care and support to our clients and families every day.



Our journey from a ‘Good’ to ‘Outstanding’ CQC rating 

On the 6th to the 13th of July 2022, the CQC completed their comprehensive inspection of TCS and rated us as ‘Outstanding’. This is a fantastic achievement for us and shows how we have progressed since our previous inspection in 2016, when we received an overall ‘Good’ rating from the CQC.

The CQC rates a care provider as ‘Good’ when they provide a service that is performing well and meeting their expectations. An ‘Outstanding’ rating is when the CQC determines the care provider to deliver a service that is performing exceptionally well.

Since our previous inspection in 2016, we have implemented effective strategies, plans and pathways to strive for an outstanding rating across each of the CQC’s KLOEs - Safe, Effective, Caring, Responsive and Well-Led.

To talk you through the successful changes TCS has implemented over the years across each of the five KLOEs, our Chief Nurses, Thomas Dowle and Clare Metcalfe, have filmed videos answering the five questions the CQC asked us.


  1. Are they safe?

    The CQC ask this question to ensure clients are safe and protected from abuse and avoidance of harm at all times.



  2. Are they effective?

    This question determines how effective the care, treatment and support offered achieves positive outcomes and helps maintain quality of life, based on the best possible evidence.



  3.  Are they caring?

    This question focuses on the wellbeing of people. It determines if those who use the service feel they are treated with compassion, kindness, dignity and respect.



  4. Are they responsive to people’s needs?

    The CQC will determine if the care provider is responsive and meets the needs of service users.



  5. Are they well-led?

    The CQC will assess the leadership, management and governance of the care provider. They will also review if the care is based on individuals' needs and whether they promote an open and equal culture.


Key highlights of the report

The CQC inspected the quality of care and the services we deliver to our clients in the community. Their report contains a detailed overview of the inspection and the key areas that make TCS 'Outstanding', key highlights from the report include:


Our clients are at the centre of everything we do

We understand our clients’ needs and how to keep them safe. Some of the people we care for display high-risk behaviours as they are unable to verbally communicate their concerns. From the CQC report, we learned that 90% of our clients feel we ‘offer high-quality care’ and 95% feel they are treated ‘with kindness, respect, and compassion at all times.’ At TCS, we ensure that we continuously monitor, review and assess every aspect of our clients’ needs, so the data we obtain drives everything we do.

We work closely with our healthcare professionals to support our clients in leading healthier and independent lives, that enable them to make decisions about the care they receive. We have successfully implemented a proactive and person-centred approach to managing risks and providing specialist support, especially to those with mental health needs, learning disabilities, autism and complex safeguarding concerns.


Frameworks to ensure individualised care

The CQC identified that we are embedding a highly individualised approach to managing service users’ care. They mentioned our teams especially supported clients with mental health, learning disabilities and autism through creativity and collaboration.

Positive Behaviour Support (PBS) and Restraint Reduction Network (RRN)

Any risks are managed in the least restrictive way possible through the Positive Behavioural Support (PBS) pathway and the Restraint Reduction Network Plan (RRN). Both practices enable focus on specific interventions which aim to reduce restrictions and increase personal choice and quality of life. 


Comprehensive systems and processes are in place

We’re committed to reviewing and analysing all data across our services, so we continue to tailor our clients care to the individual and their needs. A few examples of the data we monitor and review are:

  • Overall behaviours
  • Trends within incidents
  • Complaints
  • Safeguarding

By analysing our clients' individual incidents and challenges, we can identify their current quality of life and emotions. We can then evaluate and determine areas to improve to ensure our clients have a person-centred bespoke care plan that focuses on personal growth, independence and autonomy.

Alongside our processes and systems to support our clients' development, we have implemented a strategy to monitor service performance and inform improvement plans. That includes our Power BI Dashboard, regular business review meetings, our data management platform, IQX and the implementation of Total Mobile, a workforce management platform.


Tailored care services to meet individual needs

We've tailored our services to meet the needs of our clients and enable high levels of flexibility, personal choice and continuity of care. We've also appointed a Customer Service Lead who contacts every service user before their care packaging commences and will follow up four weeks after for a check-in call.

We regularly review data across our services to determine opportunities to further improve our bespoke care plans. We also conduct monthly reviews with clients and families, quarterly feedback surveys from all stakeholders and in-depth interviews to ensure our clients and stakeholders receive the best possible experience.

To further drive improvement in our customer experience, our Senior Leadership Team has reviewed and increased the target for overall customer experience from 85% to 95%. The CQC's report mentioned they’ve seen an improvement in overall service user satisfaction in the 12 months prior to their inspection.

Don't forget, you can submit your feedback to the CQC via their Share your experience feature here.


How TCS can support you

For more information about the services we offer or to book a no-obligation meeting with one of our specialist business managers, please complete the enquiry form below.

Please note - if you are looking to register or apply to work for Thornbury Community Services as a Nurse or a Support Worker please click here.