Pear Tree Residential Care Home

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 remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was still in breach of the legal regulation in relation to people’s safe care and treatment and safe staffing.

This service scored 41 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems and processes were not in place to support the service to learn from accidents and incidents. Accidents and incidents were not consistently documented or reviewed appropriately by managers. We found evidence of people sustaining injuries which were not recorded within the accident and incident record. Incidents were not investigated to understand why they had occurred and to ensure lessons could be learned and risk mitigated. It was not clear if relatives had been informed following incidents and we saw no evidence of an apology offered to people when things went wrong.

The provider did not always record how they worked with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People's health needs were not always clearly documented, and associated risks were not always considered. People's records did not contain up to date information regarding their care and support, including instructions from visiting professionals. Hospital passports were not always in place to ensure continuity of care.

The provider was using CCTV within the communal areas of the service but did not adhere to the requirements around the use of CCTV.

People had access to health professionals when required.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The provider’s safeguarding policy was not service specific and did not provide sufficient guidance for staff to support them in raising a safeguarding concern. The provider told us there had been no safeguarding concerns in the last year. However, we found incidents that had not been appropriately recorded, reviewed and shared with the local authority safeguarding team. We shared our concerns with the local authority.

Not all staff had completed mandatory safeguarding training or completed their yearly refresher training. We saw no evidence that staff with additional responsibilities had received a higher level of safeguarding training. Staff told us they would speak to senior members of staff to raise concerns and were aware of how to escalate concerns if necessary.

The service was unable to demonstrate consistent compliance with the Mental Capacity Act (MCA) 2005, ensure that people’s rights were protected and that any deprivation of liberty was properly authorised, understood, and applied in practice. The provider did not have a good oversight of Deprivation of Liberty Safeguards (DoLS) that some people were subject to. The conditions and other essential information in relation to the DoLS was not readily available or clearly documented so we could not be assured that these were being followed.

The provider did not always work well with people to understand and manage risks.

The provider failed to identify, assess and act on risks to people to keep them safe from the risk of harm. For example, one person on anti-coagulants, blood thinning medicines did not have an appropriate risk assessment in place. This posed a risk of excessive bleeding if they were to be injured or if they had a fall.

The provider had not always assessed and managed risks relating to people's specific health conditions. Care plans did not contain information regarding potential risks relating to people's health needs and how to mitigate these. For example, one person who had epilepsy had no care plan or risk assessment in place to guide staff how to support and monitor the person.

Risk assessments were not reviewed and updated following an incident or any changes in the persons presentation, to ensure they were still up to date and relevant.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider failed to identify and address health and safety concerns in the building. Regular audits, safety checks of the service and equipment were not completed to highlight and address concerns. This included checks on window restrictors, bed rails and fire doors. We found a fire escape blocked and some faulty or ineffective fire doors. We raised these concerns with the Humber Fire and Rescue service who planned to visit the service.

9 of the 25 staff had not completed fire safety training including the registered manager.

The provider failed to take action to address faulty emergency lighting which had been identified in May 2025. Following our feedback the provider took action to address these concerns.

The service was not safely storing cleaning chemicals in line with Control of Substances Hazardous to Health guidance (COSHH). When we raised this with the registered manager, they told us they were aware but had taken no action to address this.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The provider had failed to carry out mandatory safe recruitment checks to ensure staff were suitable to work with vulnerable adults. New staff and staff on zero-hour contracts, also known as bank staff, had not been provided with mandatory training before working in the service.

Care staff were required to prepare and serve breakfast and evening meals for people; however, only 3 of the 16 care staff had completed their food hygiene training.

A significant amount of mandatory training was out of date, had not been completed by staff, or had not been made available by the provider. This meant we could not be assured staff had the right skills and experience to safely support people.

Most people and relatives told us there was enough staff to meet people’s needs. One person told us, “The staff are always around if I need them.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection, Prevention and Control (IPC) audits were not completed on a regular basis and there were concerns raised by staff around the management of infections within the service. IPC policies were not up to date or service specific. Only 1 of the 3 domestic staff had completed infection prevention control training and a staff member with additional IPC responsibilities had not completed the required training.

One area of the service was in need of maintenance and repair as the integrity of the surfaces were compromised and so could not be effectively cleaned. Personal Protective Equipment (PPE) was stored correctly and we observed staff using this appropriately.

The service was clean and tidy and one relative told us, “It’s kept very clean there, I’ve seen the cleaners going round, it’s kept nice.”

Systems and process did not always ensure effective oversight to ensure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Staff with responsibilities around medicines administering had not always completed the required training. The registered manager told us a review of medication training was not required which was not in line with best practice guidance.

Audits were completed regularly. However, these focused on stock levels and did not look at other areas of compliance such as storage and recording.

Where people’s medicines were given covertly, the correct process around assessing capacity and having a best interest decision had not taken place, and families were not always consulted.

People did receive their medicines as prescribed and on time. Medicines were stored safely and securely.