This inspection was carried out on the 10 and 14 November 2017 and was unannounced.

The Children's Trust Tadworth is a charity that works with children and young people who as a result of an acquired brain injury have multiple disabilities and complex health needs. They offer a range of services which include rehabilitation for children and young people and respite care which is accessed via the child's local authority. They also offer rehabilitation for children who have long term disorders of consciousness and attend The Children's Trust School.

The Children's Trust offers an online information hub which includes education and advice concerning aspects of caring for children with acquired brain injuries. This service is a national resource and openly accessible to people and professionals in the community. Additionally there are two support teams, one based in the community and the other based in key NHS hospitals across the country offering advice and support within their local geographical areas. There is also an onsite school providing education to children and young people. The school is regulated by Ofsted (the regulator for education and children services).

The Children's Trust offers accommodation for children and young people within seven units/houses. For those children for whom The Children's Trust is effectively their permanent home, three houses are registered jointly with Ofsted. The remaining four houses are registered with only the Care Quality Commission (CQC) as the children have limited stays, albeit with high medical needs. At the time of our inspection 44 children were in receipt of care. Throughout this report children and young adults will be referred to as ‘people or person.’ At the time of writing this report decisions were being made about who the primary regulator should be and which regulated activity would be inspected by Ofsted and CQC.

At the previous inspection in September 2016 we identified a breach in relation to medicines and how records were stored. At this inspection this had now improved.

Staff worked creatively with people and their relatives to involve them in the management of their medicines. They employed a pharmacist who worked with other health care professionals, people and relatives to help streamline the management of their medicines. Staff ensured that people received their medicines on time, as intended and in a safe way. Staff engaged with health care professionals to review people’s medicines. Research about the causes of medicines incidents had taken place and their findings and recommendations were discussed with staff.

The Trust undertook research in a number of ways to ensure that only the best care was being provided. The service contributed to the development of best practice and good leadership with other agencies. Learning took place from the research and changes made to how care was delivered. There were a whole range of health care professionals that worked at the Trust that ensured they were up to date with best practice and current guidance. Comprehensive training was provided to all staff. Relatives were also provided with training around the equipment that their family member needed.

People and their relatives felt that the care that was provided exceeded their expectations. Staff demonstrated a real empath for people they cared for. Staff involved and treated people and relatives with compassion, kindness, dignity and respect. We saw staff treat people in a caring way. People's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. People's privacy and dignity were respected and promoted when personal care was undertaken. People and relatives felt that staff went the ‘extra mile’ in relation to the care that was provided. For example one person was supported by staff to have their dream holiday abroad.

Staff used innovative ways of involving people and their relatives i

This inspection took place on 20, 21 and 27 September 2016 and was unannounced on the first day. The service was last inspected in January 2014 and at that time was meeting all the regulations we looked at.

The Children's Trust Tadworth is a charity that works with children and young people who as a result of an acquired brain injury have multiple disabilities and complex health needs. They offer a range of services which include rehabilitation for children and young people and respite care which is accessed via the child’s local authority. They also offer rehabilitation for children who have long term disorders of consciousness and attend The Children's Trust School.

The Children’s Trust offers an online information hub which includes education and advice concerning aspects of caring for children with acquired brain injuries. This service is a national resource and openly accessible to people and professionals in the community. Additionally there are two support teams, one based in the community and the other based in key NHS hospitals across the country offering advice and support within their local geographical areas.

There is also an onsite school providing education to children and young people. The school is regulated by Ofsted (the regulator for education and children services).

The Children’s Trust offers accommodation for children and young people within seven units/houses. For those children for whom The Children’s Trust is effectively their permanent home, three houses are registered jointly with Ofsted. The remaining four houses are registered with only the Care Quality Commission (CQC) as the children have limited stays albeit with high medical needs. This inspection was conducted at the same time as Ofsted, but ran in parallel as the purpose and role of each regulator is different.

At the time of the inspection The Children’s Trust there were 49 out of a maximum of 77 children or young people accommodated at the service in Tadworth. Because of difficulties associated with finding suitable alternative placements for young people older than 18 years within their home local authorities, a number of young adults were accommodated by The Children’s Trust between the ages of 18 and 23.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Whilst we acknowledge the large volume of medicines administered safely by the service on a daily basis, there were some areas of concern. Refrigerator temperatures for the storage of some medicines did not include a maximum and minimum measurements. This meant we could not be sure medicines were stored correctly. Also a dose of a medicine dispensed and labelled for one child was administered to another child under the supervision of a doctor.

The Children’s Trust maintains dual records for children and young people, either as paper records or computer based. This dual system sometimes led to incomplete information which meant current and up to date information about children was not always available. We found some daily records were not always contemporaneous, and on occasions therapists updated care plans but had not always signed or dated them so it was unclear when or who had updated them.

We identified two breaches of the Health and Social Care (Regulated Activities) Regulations 2014 during our inspection. You can see what action we told the provider to take at the back of the full version of this report.

People we spoke with were positive about the care and support they and their children received from The Children’s Trust. Staff were knowledgeable about the children and young people they supported. Levels of staffing were sufficient to ensure th

During our visit we spoke with two children who used the service, three relatives of children and nine members of staff. We observed how staff engaged with the children and also with their family representatives.

People spoke very positively about The Children's Trust. Family members told us they felt involved with their children's care, both during the assessment and delivery stages of care provision. One person said "They look after us all very well. I feel that my child is safe and I can trust the staff to look after my child when I am not here". Another person said "If I have a problem I can speak with a staff member; sometimes it is a matter of mis-communication between the teams but the staff work hard to resolve any problems very quickly".

Staff told us that the organisation was going through managerial change which was, on balance a "Positive move for the organisation".

We found that children's needs were assessed and care and treatment was delivered to ensure the safety and welfare of the children who used the service.

The location was found to be clean and tidy; the service had taken action to resolve areas of previous non-compliance with infection control processes.

Staff received training, support and supervision on a regular basis.

There were appropriate quality assurance systems in place which evidenced that the Provider was taking action to improve the quality of the service provided by listening to people's feedback.

At the time of this inspection this service did not have a Registered Manager in post as the existing post-holder had recently left the organisation. The Provider was taking action to appoint a new Registered Manager to oversee the Regulated Activities to which this service is registered for as per the conditions of their registration.

As part of this inspection we were required to speak with representatives from Ofsted, the Regulator who is responsible for inspecting and regulating services who provide care for children and young people and those providing education and skills for learners of all ages. The School for Profound Education is located on the main campus and forms part of the Children's Trust and is currently regulated by Ofsted. We were asked to consider whether the School for Profound Education should be jointly registered with Ofsted and CQC due to the changing needs of the children and young people who use the service. Ofsted are responsible for regulating the social care needs of children and young people whilst the Care Quality Commission (CQC) are responsible for regulating the health needs of children, young people and adults.

We will continue to work with the Provider and Ofsted to determine whether the School for Profound Education should be jointly registered with both Regulators.

Therefore, this report details our findings associated with the care provided within the Rehabilitation Service which is located at The Children's Trust, Tadworth and is exclusive of the care provided at The School for Profound Education.

During our visit we spoke with one child who used the service, four relatives of children who used the service and seven members of staff. We observed how staff interacted with and supported children and their families.

Relatives we spoke with told us they always felt included in any decisions about care and treatment for their child. One relative told us that the staff “Always discuss the possible side effects of any treatment.”

We observed that staff provided care with patience and in a way that made children feel relaxed. All of relatives we spoke with thought that the care that the staff provided was excellent. One member of staff we spoke with told us that “All of the staff go above and beyond” to provide care.

The relatives we spoke with told us that the service was always clean and tidy. However we found that not all of the infection controls were in place. There were no schedules or rotas that directed staff to what needed cleaning or what had been cleaned.

We saw that there were adequate numbers of qualified staff at the service on the day of our inspection.

The service had systems in place that monitored the quality of the service and identified when things needed to be improved.

It was possible to communicate to some of the children through staff, gestures, or facial expressions.

One child told us that she was enjoying her speech therapy session when we visited her there. Another expressed himself with a thumbs up sign during his physiotherapy session. Another made head movements during his music therapy session that he was enjoying it.