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Short Break Service Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 August 2019

About the service:

The short break service is a care home providing respite care for up to three adults who live with complex needs associated with autism and/or a learning disability. During the course of the inspection, two people were using the service.

People’s experience of using this service:

Accommodation used by the service had undergone a recent refurbishment.

However, some aspects of the environment and surroundings had not been developed and designed in line with the principles and values that underpin CQC's policy for Registering the Right Support, the fundamental standards, and other best practice guidance. This meant the refurbishment had not been completed in a way that best supports people who live with autism and/or a learning disability.

A number of safety issues were identified associated with a refurbishment. The building had reopened before an updated fire risk assessment had been completed; grab rails had not been fitted in the newly refurbished communal bathrooms; no environmental risk assessments had been completed; and the outside garden area was found to be poorly maintained and not a safe space for people to access within a care setting.

There was an organisation structure in place, but the lines of accountability were not always clear. Nurse managers were required to navigate multiple departments and a variety of different officers when escalating concerns or seeking to find solutions.

Medicines systems were organised and people were receiving their medicines when they should. The provider was following safe protocols for the receipt, storage, administration and disposal of medicines.

The provider had effective safeguarding systems and policies and procedures which sought to protect people from abuse.

People had personal risk assessments in place and Positive Behaviour Support (PBS) plans. This was complimented by the fact staff knew people well.

Before a person started using the service, an initial assessment was completed with people and their relatives to ensure care was planned proactively and in partnership with them. Care plans were then reviewed and before each short break stay.

Staff had the required knowledge, experience and skills to meet people’s needs. Staff received a range of appropriate training applicable to their role.

The ethos of the service supported people's rights to make choice. This was well reflected in the good care and support people received from a committed and caring group of staff.

We observed staff demonstrating kindness, patience and respect and people were given time to express themselves fully. Staff knew people well and interactions were relaxed.

Rating at last inspection:

The service was newly registered on 01 October 2017. This was the first comprehensive inspection since new registration.

Why we inspected:

This was a routine planned inspection.


At this inspection we identified breaches of legal requirements in relation to safe care and treatment and buildings and premises. You can see what action we have taken at the back of the full report.

Follow up:

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and other relevant stakeholders to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 15 August 2019

The service was not always safe.

Details are in our Safe findings below.


Requires improvement

Updated 15 August 2019

The service was not always effective.

Details are in our Effective findings below.



Updated 15 August 2019

The service was caring.

Details are in our Caring findings below.



Updated 15 August 2019

The service was responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 15 August 2019

The service was not always well-led.

Details are in our Well-Led findings below.