CQC report explained · a residential care home
What the CQC found at Short Break Service
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found effective systems for managing risks, safeguarding, medicines and infection control. The garden had been made safe and the earlier breach about safe care and treatment had been resolved.
- Effective?
- Good
- The environment had been improved to meet people's needs, and staff had suitable training and knowledge. Dietary needs, healthcare support and consent arrangements were managed appropriately.
- Caring?
- Good
- This question was not assessed during this focused inspection.
- Responsive?
- Good
- This question was not assessed during this focused inspection.
- Well-led?
- Good
- Management oversight and quality checks had improved and were sustained. Roles and staffing structures were clearer, with new management posts in place.
What inspectors found, December 2020
Short Break Service was rated Good, with inspectors finding safer care, suitable improvements and stronger management than at the previous inspection.
The home provides planned and unplanned short breaks for up to three adults with complex needs linked to autism or a learning disability. Inspectors visited on 8 October 2020, reviewed records and spoke by telephone with four relatives and five staff. They could not speak directly with people using the home.
The home was rated Good for Safe, Effective and Well-led. Inspectors found that risks, medicines, infection control and safeguarding were managed effectively. The environment had also improved, including the garden, bedrooms, seating and internet access.
This was a focused inspection following a Requires Improvement rating in May 2019. The home had previously breached requirements about safe care and treatment and premises and equipment, but inspectors found enough improvement had been made and those breaches no longer applied. Caring and Responsive were not assessed during this visit, so their previous ratings were carried forward.
Safer environment
Inspectors found that environmental risks had been assessed and that the garden had been made safe and accessible.
“The outside garden area had been made safe with all environmental hazards removed.” from the report
Medicines managed safely
The home had organised systems for receiving, storing, giving and disposing of medicines.
“Medicines systems were organised, and people received their medicines when they should.” from the report
Better support for individual needs
Rooms were adapted for each person’s visits, and families and people using the home were involved in environmental improvements.
“Rooms were individualised to people who use the service on a visit by visit basis to ensure an appropriate environment” from the report
Stronger management
Inspectors found that management oversight and quality assurance had improved and continued to operate.
“Improvements had been made, and sustained, to strengthen management oversight and quality assurance.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you complete and review individual garden and other environmental risk assessments?
- 02How will you make sure my relative receives their medicines safely and on time?
- 03How are rooms adapted for each person’s visit, and how are my relative’s choices included?
- 04How do you monitor whether the improvements made after the May 2019 inspection are being maintained?
- 05How will you gather my relative’s views if they cannot communicate directly with inspectors or staff?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and their previous ratings were carried forward. This explanation was written from the published report of 30 December 2020 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.
What inspectors found, August 2019
Short Break Service rated Requires Improvement; inspectors found kind, responsive care but safety, premises and management needed significant improvement.
This was the first comprehensive inspection since the home was registered. Inspectors visited on 13, 14 and 16 May 2019. They reviewed care and staff records, spoke with people, relatives and staff, and observed care.
The home provided short breaks for up to three adults with complex needs linked to autism or a learning disability. Inspectors found caring and responsive support. Staff knew people well, treated them with kindness and respect, and planned care around their needs and choices.
However, the refurbished building had safety problems. These included no updated fire risk assessment when it reopened, missing bathroom grab rails, no environmental risk assessments and an unsafe garden. The home also lacked suitable sensory equipment. Management had not dealt with some known risks quickly enough.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good. The report identified breaches of legal requirements relating to safe care and treatment and premises and equipment.
Kind and respectful care
Staff knew people well and supported them patiently. People were given time to express themselves and were involved in choices about their care.
“We observed staff demonstrating kindness, patience and respect and people were given time to express themselves fully.” from the report
Reliable medicines systems
Inspectors found that medicines were given when they should be. The home had safe systems for receiving, storing, administering and disposing of medicines.
“Medicines systems were organised and people were receiving their medicines when they should.” from the report
Skilled staff
Staff had the knowledge and training needed for their roles. Staff also understood people's individual needs and dietary requirements.
“Staff had the required knowledge, experience and skills to meet people's needs.” from the report
Personalised planning
The home assessed people before their stay and reviewed plans before each short break. Plans included people's histories, preferences, communication needs and support requirements.
“Before a person started using the service, an initial assessment was completed with people and their relatives” from the report
Fire and environmental safety
seriousThe building reopened before an updated fire risk assessment was completed. There were also no environmental risk assessments, which meant hazards had not been properly identified and reduced.
“The building had reopened before an updated fire risk assessment had been completed.” from the report
Unsafe garden
seriousThe garden was overgrown and had uneven surfaces. A worn swing had no risk assessment or maintenance records to show it was safe.
“The garden was overgrown and had uneven surfaces.” from the report
Missing bathroom equipment
seriousGrab rails had not been fitted in the newly refurbished communal bathrooms. Staff said this made personal care more difficult and increased the risk of falls.
“grab rails had not been fitted in the newly refurbished communal bathrooms” from the report
Environment not suited to people's needs
needs fixingThe home lacked suitable sensory equipment and some seating was damaged and worn. Inspectors said the refurbishment did not fully reflect best practice for people with autism or a learning disability.
“The interior of the home was basic and functional but did not support a therapeutic or homely environment.” from the report
Slow response to known risks
needs fixingInspectors found that some risks had been known for a long time but had not been dealt with promptly. Accountability between different parts of the organisation was not always clear.
“the provider had not acted in a timely way to mitigate risks already known to them.” from the report
- 01What changes have been made to the garden, including its surfaces and the swing, and what current risk assessments and maintenance records are available?
- 02Have grab rails now been fitted in the communal bathrooms, and how are falls risks managed during personal care?
- 03When was the latest fire risk assessment completed, and have all actions from it been completed?
- 04What sensory equipment and suitable seating are now available for people who become distressed?
- 05How are responsibility and accountability for maintenance, safety issues and internet access now managed?
This was the first comprehensive inspection since registration and covered all five CQC questions, including both the premises and the care provided. This explanation was written from the published report of 15 August 2019 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 Short Break Service
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- December 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- October 2017
Registered with the Care Quality Commission on 1 October 2017.
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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