PCAS Kent Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of the legal regulation in relation to safeguarding, safe care and treatment and staffing.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Incidents were not always recorded and reported by staff, and when they were recorded, the information was not always accurate. For example, an incident had been detailed as a ligature incident, however this had not been reviewed or preventative measures taken. Following the assessment, the provider reviewed and found it was not a ligature incident, however this had not been identified prior to our assessment. The provider had not completed an analysis of incidents, accidents or episodes of distress and agitation and therefore did not identify any potential trends or patterns. For example, the provider was unaware of the high number of episodes of distressed or agitation experienced by one person in one month. They had not identified potential safeguarding incidents and taken appropriate action in response. Staff told us that if there are any actions or lessons learnt from incidents, they are not always shared with staff. One staff member told us, “We never had any feedback from incidents, never any lessons learnt shared with us.”

Staff did not always have a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was not consistently proactive and effective. For example, two people’s care started with the provider as an emergency placement and not all staff had been involved or informed of the decisions to ensure they had everything in place to be able to support them safely. Staff told us, “There was no transition (plans) for this person, it could have been handled a lot better.”

However, some people did have positive transitions between services. For example, one person was supported to move temporarily but then they wanted to stay permanently. The staff supported the person to ensure that the move could be permanent.

People were not always protected from the risk of harm or abuse. Systems and practices in place to make sure people were protected from abuse and neglect were not effective. The provider had not always taken action, even when abuse had been identified. One person told us they did not feel safe in their home, they told us “It makes me angry when [person] shouts and I feel scared and upset.” Staff told us, “This has been going on for years, [person] terrorises [person].” Senior leaders told us they were not aware of the extent of the situation within this one home and that this would occur when staff were not present.

The provider told us there had not been any incidents between people in one of the homes, however we identified two potential safeguarding incidents that had occurred within that home between people that lived there. These incidents had been recorded by staff but had not been reviewed and therefore action had not been taken. People were not being safeguarded from harm and abuse.

People were not always appropriately supported when they experienced distress. An incident between a person and a staff member detailed it ‘took 3 members of staff to loosen person’s grip’. There was no other information on how staff supported the person, and we could not be assured proportionate and appropriate action was taken to support the person. The provider had not investigated this incident to ascertain if unplanned restraint was used and if this was proportionate. The risk assessment for this person did not provide any information around restraint and the provider told us they do not restrain anybody.

Whilst we identified significant safeguarding concerns relating to two of the supported living homes, some people from other homes told us they did feel safe.

People’s health risks were not consistently well managed and mitigated. Guidance on how to support people at risk of constipation or those who could experience distressed behaviours was not robust. In January 2025 one person experienced 41 episodes of distress or agitation, resulting in altercations with people and physical altercations with staff. The persons care plan was not robust to ensure staff had the guidance they needed to support the person safely.

People who were at risk of constipation did not have robust guidance in place but where there was some guidance, staff did not always follow this. One person’s care plan detailed they were prescribed a medicine to take ‘when needed’ for constipation. However, the bowel monitoring chart detailed they had not opened their bowels for 8 days and this medicine had not been given. The guidance for staff was limited and did not include what signs and symptoms staff need to look out for, when to seek medical advice or what to do in an emergency or information around the increased risk of constipation for people with a learning disability.

People who lived with epilepsy did not have detailed guidance in place regarding the increased risks of having epilepsy, including the risk of sudden death in epilepsy. The care plans did not highlight this risk to people.

The provider did not always detect and control potential risks to people in their care environment. People’s personal emergency evacuation plans (PEEP) were not always updated to reflect the person’s current health and needs. One person’s evacuation plan detailed they could use their walker to exit the building in an emergency. However, the person was now cared for in bed and the guidance had not been updated to detail how to support this person to evacuate.

People’s relatives told us they did not have any concerns regarding the environment. A relative told us “The environment is kept well and tidy.”

The provider did not always make sure there were enough qualified, skilled and experienced staff to support people. Staff did not always receive training to ensure they were competent for their role, including supporting people with anxious or distressed behaviours. For example, four staff that had been involved in physical incidents had not completed face to face training to support people who were distressed. Staff told us, “Staff are getting hit, we [staff] just need more in-depth training around this.” Medicine competencies were not complete and up to date for the staff that administered medicines and therefore the provider could not be assured that staff were administering and managing medicines safely. Another staff member told us, “We are setting staff up to fail, there is no briefing and limited training there is no wellbeing.”

The induction staff received did not ensure they had the skills and competence for their role. The majority of staff fed back to us that they felt the number of shadowing hours was not enough to ensure they could support people safely. One staff member told us, “The induction could be more in depth. The shadowing is not long enough, I had one full day and that was it but we didn’t even get to go to another service which was really daunting.

Another staff member told us, “There is no flexibility with shadowing, it has been challenged and the response is 5 hours only.” Another staff member told us, “Staff get 5 hours of shadowing, that is not enough and we cannot extend that.” This meant that staff were not given the support they needed from the provider to ensure they were confident in their role and had the knowledge to support people.

The provider had not ensured that infection prevention and control (IPC) measures were consistently managed. Some staff had not completed training around Control of Substances Hazardous to Health (COSHH) regulations. The provider could not be assured that all staff were competent regarding IPC. A weekly spot check identified that hazardous waste was exposed in the bins outside one of the homes. It was not clear what action had been taken to address this.

People’s relatives fed back that they were happy with the cleanliness of the homes and that some of their loved ones were supported by staff to maintain a clean environment.

The provider did not always make sure medicines were managed safely. Where fridge temperatures were being recorded by staff for one persons’ medicines, this was not completed consistently and there were some days it was not recorded. If the medicine is not stored at the correct temperature it can effect the efficacy of the medicine which can lead to the desired outcome of the medicine not being achieved.

The provider did not always ensure effective guidance was in place for staff to follow regarding some medicines. For example, one person’s medicine should not be taken 30 minutes before or after caffeinated drinks, however there was no detail or guidance in place regarding this advised restriction for staff to follow. We could not be assured staff were aware of this restriction which meant there was a risk the desired effect of the medicine could be altered if caffeine was consumed within that time window.

Whilst we found areas for improvement, we identified areas of good practise. For example, medication administration records were complete, and people told us staff supported them to take their medicines on time.