CQC report explained · a residential care home
What the CQC found at Short Term Breaks - 69 Neithrop Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, clear risk guidance, safe medicines practice and suitable infection control arrangements.
- Effective?
- Good
- This area was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This area was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This area was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Management and quality checks had improved. Records were being reviewed, staff understood their roles and the provider was no longer in breach of Regulation 17.
What inspectors found, December 2021
Short Term Breaks - 69 Neithrop Avenue was rated Good after improving from Requires Improvement; inspectors found safe, person-centred care and stronger management systems.
This was a focused inspection on 13 December 2021. The inspectors checked Safe and Well-led, including infection control, records, medicines, staffing and management systems. They spoke with people, staff, the manager and relatives, and reviewed care, medicine and quality records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, clear risk assessments, safer medicine records and suitable infection control measures. People were protected from abuse and staff knew how to report concerns.
The home had improved since the previous inspection, when it was rated Requires Improvement and breached Regulation 17. At this inspection, the provider was no longer in breach and the overall rating changed to Good. The other three areas were not assessed during this visit, so their previous ratings were carried forward.
Personalised support
Support was tailored to people's needs and preferences. Staff respected people's choices, privacy and wish to have time alone.
“People received personalised care and support specific to their needs and preferences.” from the report
Safe staffing
Inspectors found enough staff to meet people's needs. Staff were seen spending time with people and were not rushed.
“There were enough staff working to provide the support people needed.” from the report
Improved records and checks
The home introduced better checks on care records, medicines, training and health and safety. This addressed the previous governance problem.
“Quality assurance systems were effective, and we saw a sample of audits, checks and monitoring systems including; medicines, training and health and safety.” from the report
Positive culture
People appeared relaxed with staff, and staff spoke about people with care and compassion. Relatives gave positive feedback about communication and the way the home was run.
“The culture of the service was positive with staff speaking about people who used the service with care and compassion.” from the report
Use of agency staff
minorOne relative was concerned about the high use of agency staff. The manager said this was expected to reduce when two people moved to permanent homes.
“Relatives were happy with the staff team, although one commented on the high use of agency staff.” from the report
Health information from relatives
minorSome information about people's contact with health professionals was not yet available. The manager was looking for an easier way for relatives to provide it.
“The registered manager said some relatives had not provided information about when people had seen health professionals.” from the report
- 01How much agency staff are currently being used, and how will you keep support consistent for people who stay here?
- 02How do you obtain and update information from relatives about people's appointments and contact with health professionals?
- 03How often are each person's care records, medicine protocols and risk assessments reviewed?
- 04What progress has been made with the planned sensory room and other improvements to the home?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 25 December 2021 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, November 2019
Short Term Breaks - 69 Neithrop Avenue was rated Requires Improvement; care was kind and person-centred, but records and quality checks were not reliable enough.
Inspectors visited on 10, 16 and 17 October 2019. They spoke with people using the home, staff, relatives and a social care professional. They also checked care records, medicines, staff files and management records.
People were treated kindly and supported to make choices. Inspectors found enough staff, safe recruitment, clean areas, suitable activities and good support for people's communication, health and independence. The ratings for Effective, Caring and Responsive were Good.
The main problem was that records were not always complete, signed or up to date. Around 20 people's support plans still needed checking, some health documents were out of date, and not everyone initially had the required medicines information. The home acted during and after the inspection, but inspectors found that its checks had not identified these problems quickly enough.
The overall rating was Requires Improvement. Safe and Well-led were both Requires Improvement. This was the first inspection of the newly registered service under the new provider, although the previous rating of Good was used to help plan the inspection.
Kind and respectful care
People and relatives described staff as kind and caring. Staff listened to people, respected privacy and adapted the environment when needed.
“The staff are kind.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. People were supported promptly and staff did not appear rushed.
“There were enough staff to meet people's needs. We saw people were supported in a timely manner and staff were not rushed.” from the report
Choice and activities
People were involved in their support and were offered activities and outings during their stays. The home considered compatibility so people could spend time with others they got on with.
“One person described the different things they did, such as going out for meals and going to the cinema.” from the report
Staff skills and training
Staff received induction, training, supervision and competency checks. Inspectors found they had the skills and knowledge to support people's needs.
“People were supported by staff who had the skills and knowledge to meet their needs as they received ongoing training and guidance.” from the report
Incomplete and outdated records
seriousSupport plans, health action plans and health passports were not always complete or current. Some records were unsigned or contained conflicting risk information, which could leave staff without the information they need.
“The provider's quality assurance processes were not always effective.” from the report
Medicines information was missing at first
seriousOn the first inspection day, not everyone had medicine profiles or protocols for medicines given when needed. These were completed by the second day, but the gap contributed to the Safe rating of Requires Improvement.
“Medicines were not always managed safely as there were areas that needed some improvement with regards to records.” from the report
Quality checks missed problems
seriousAudits and monitoring did not identify all the missing or outdated documents. The provider acted by setting responsibilities and a deadline for updating the records.
“This monitoring visit had not highlighted the work needed to be done to ensure people's records were all checked and up to date.” from the report
- 01Have all support plans now been checked and updated, and how often will they be reviewed?
- 02Does my relative have a current medicines profile and written instructions for any medicines given when needed?
- 03Does my relative have a current health passport and health action plan?
- 04How do you check that staff sign records and that risk information is complete and consistent?
- 05What changes have been made following the Regulation 17 breach, and what evidence can you show that they are working?
This was an announced comprehensive inspection of the home, including the premises and care, covering all five CQC questions. This explanation was written from the published report of 15 November 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 Term Breaks - 69 Neithrop Avenue
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- December 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Short Term Breaks - 69 Neithrop Avenue →
- November 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Short Term Breaks - 69 Neithrop Avenue →
- October 2018
Registered with the Care Quality Commission on 16 October 2018.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
38 live-in carers within about an hour of Oxfordshire
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 £980 to £1,300 a week. 32 can care for a couple. 12 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She was v competent and confident and we felt our mum was safe in her care. She supported us through a difficult time.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.