This focused inspection found Swindon Family Breaks Service had made sufficient improvements since its previous 'Requires Improvement' rating, resolving a breach of Regulation 12 and strengthening safeguarding, medicines management and governance. Both Safe and Well-Led key questions were rated Good, raising the overall rating to Good.
Concerns (1)
moderateRecord keeping: “We identified a shortfall within the recruitment process which limited the providers oversight and opportunity for staff recruitment histories and references to be adequately scrutinised.”
Strengths
· Personal risk assessments were regularly reviewed and updated; emergency and fire evacuation plans were in place and well understood by staff.
· Safeguarding procedures were strengthened since the last inspection; staff felt confident raising concerns with leadership.
· Medicines management processes were improved, including GP summaries and pre-stay medication checks with families.
· Infection prevention and control measures were fully assured across all assessed criteria.
· Strong learning culture with incident review, updated risk assessments and care plans following adverse events.
Swindon Family Breaks Service was rated Requires Improvement overall following a focused inspection of Safe and Well-Led, with a breach of Regulation 12 identified due to out-of-date care records, inconsistent risk monitoring, and inadequate safeguarding escalation systems. Governance processes failed to identify these shortfalls prior to inspection, though the registered manager demonstrated willingness to improve and took immediate remedial action.
Concerns (7)
criticalCare planning: “one person's epilepsy protocol had not been reviewed since 2016 and contained out-of-date information about the person's medicines.”
criticalRecord keeping: “one person's epilepsy protocol stated they needed to be checked on every 30 minutes, however their risk assessment stated the checks were to be completed every 15 minutes.”
criticalSafeguarding: “The provider had no effective system in place that could provide staff with information about their responsibilities and where to escalate their safeguarding concerns.”
criticalStaff competency: “not all staff signed the document to confirm they were familiar with people's care plans... staff did not always follow appropriate guidance when working with the person.”
moderateIncident learning: “The service did not always manage incidents affecting people's safety well. Staff recognised incidents but did not always report them appropriately.”
moderateGovernance: “Governance processes were not always effective and did not always hold staff accountable, keep people safe, protect people's rights and provide good quality care.”
moderateOther: “a fire drill was supposed to take place every three months. However, only one fire drill was recorded for 2021 and one fire drill for 2022.”
Strengths
· Staff understood and implemented STOMP principles ensuring medicines were reviewed by prescribers appropriately.
· Staffing levels were sufficient including one-to-one support; agency staff used were already familiar to people.
· Effective infection prevention and control measures were in place, with good PPE use and clean premises.
· Staff understood MCA principles and appropriate DoLS authorisations were in place.
· Registered manager set a culture valuing reflection, learning and improvement and was receptive to challenge.
Swindon Family Breaks Service achieved a Good rating across all five key questions at its February 2018 unannounced inspection, improving from Requires Improvement in December 2016. The service demonstrated strong safeguarding practice, personalised care, effective management and robust governance, with only a minor concern noted about the consistency of community outings for one person.
Concerns (1)
minorPerson-centred care: “one relative of a person told us, 'The only negative is they do not always take [person] out, so by the time he comes home he is climbing the walls to get out'”
Strengths
· People felt safe and staff understood their responsibilities for reporting safeguarding concerns
· Medicines were managed safely with staff trained and regularly assessed for competency
· Robust recruitment systems ensured staff suitability including DBS checks
· Staff received regular supervision, appraisals and comprehensive induction including Care Certificate
· Personalised care plans reflected people's preferences, communication needs and cultural backgrounds
This targeted IPC inspection of Swindon Family Breaks Service found the provider fully assured across all eight infection prevention and control domains during the COVID-19 pandemic. No failures or regulatory breaches were identified; the service was inspected but not rated.
Strengths
· Sanitising station at entrance with hand cleaning, shoe disinfection and temperature checks for all entrants
· Lateral flow device testing required for all visitors including visiting professionals
· Staff followed government PPE and IPC guidance with sufficient PPE stock monitored by registered manager
· All staff received recent IPC training and observed following correct practices including social distancing
· One-way system implemented to minimise infection risk
Quality-Statement breakdown (1)
safe: S5 How well are people protected by the prevention and control of infection?Insufficient evidence to rate
Swindon Family Breaks Service received an overall rating of Requires Improvement, driven by inconsistent night-time risk monitoring where risk assessments contradicted care plans and checks were not carried out as required, which the registered manager failed to identify through governance processes. Strengths included good medicines management, well-trained and caring staff, person-centred care plans, and effective Mental Capacity Act compliance.
Concerns (3)
criticalCare planning: “one person's risk assessment clearly stated that staff should check the person's condition at night every 15 minutes. However, according to the care plan, the person was supposed to be checked every 30 minutes.”
criticalGovernance: “systems to assess, monitor and mitigate risks to people were not always effective. The registered manager had failed to identify that three people were not receiving safe care at night.”
moderateRecord keeping: “We could not find any records of regular checks for that person. Another risk assessment stated that a different person should be regularly monitored at night. However, the risk assessment did not specify how often.”
Strengths
· People's prescribed medicines were safely managed; MAR records completed correctly with no unexplained gaps and yearly competency checks in place.
· Staff received regular supervision, appraisals and up-to-date training covering safeguarding, moving and handling, infection control and medicines management.
· The Mental Capacity Act 2005 was correctly followed; best interest meetings held where people lacked capacity.
· Care plans were person-centred, regularly reviewed, and produced in accessible formats including Makaton, pictures and symbols.
· People and relatives spoke positively about the registered manager and described an open, transparent culture.
Quality-Statement breakdown (18)
safe: Risk assessments consistent with care plansRequires improvement