694 Pinner Road

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 remains requires improvement. This meant the service was not always safe and there was an increased risk that people could be harmed.

This was because we found concerns with the learning culture in the service, the provider’s safeguarding arrangements, the management of risks and the provider’s ability to safely meet the needs of people who reside in the service. These failures placed people at risk of harm. We found breaches of 2 regulations. These were in relation to safe care and treatment and safeguarding people from the risk of abuse and improper treatment.

This service scored 50 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff we spoke with told us that team meetings were used to share information about incidents along with any learning. However, we found delays in staff reporting incidents to the service manager. The service did not always learn lessons when things went wrong. We saw a lack of evidence regarding actions taken and lessons learnt following accidents and incidents. For example, a serious incident from March 2025 involving a person was recorded, however there was no evidence of specific interventions carried out by staff, lessons learnt, or actions taken to mitigate recurrence of the risk. We saw incidents of a similar nature documented with no clear outcomes recorded. The service did not always have effective and robust systems for learning and improvement to ensure that people were receiving safe and appropriate care. The service manager informed us they would have refresher sessions with staff on good documentation practices and accidents and incidents protocol.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. The service manager informed us they planned and organised care and support with people, together with partners and relatives in ways that ensured continuity. However, the service did not always maintain safe systems of care. For example, in two care records we reviewed, we found risk assessments were not in place for specific health needs and they did not always align with suggested recommendations and outcomes in people’s care plans. Inaccurate care records could have a potential impact when people move between services because in terms of continuity of care, informed decision-making, risk management and safety.

The service 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 service did not always share concerns quickly and appropriately with the relevant authorities. The service had a clear safeguarding policy and procedure in place which were kept up to date, and easy for staff to access. According to training records, all staff had completed their training in safeguarding and were aware of external reporting processes and procedures. However, we noted accidents and incidents recorded in 1 person’s file were not considered as potential safeguarding incidents and statutory external reporting procedures were not always followed.

We observed a staff member struggling to support a person when they expressed agitation. During the assessment visit the person forced access to a padlocked cupboard in the kitchen. The staff member who was providing one to one support grabbed hold of the person’s left arm and right shoulder. No verbal interaction took place to calm the situation, and the member of staff did not manage the situation in a person-centred manner and in accordance with the person’s care plan. The provider and staff had not considered that this incident could have amounted to the improper use of physical restraint and they had not taken appropriate action to record and report this. Training records indicated that staff were not restraint trained at the time of assessment. The service had not informed the local authority safeguarding team of this incident. This meant the service did not always escalate concerns, preventing appropriate action from being taken, placing people at risk of harm.

The service did not always work well with people to understand and manage risks. Care files were not always accurate and did not contain up-to-date information that reflected the current care and support needs of people who live in the service. For example, a person’s fluid intake records were not in line with the care plan’s suggested outcome and risk assessments were not in place for a specific health need and the need to avoid certain foods. We raised this with senior leadership who have since reviewed and updated nutrition and hydration support plans and risk assessments.

Behaviour recording charts and Positive Behavioural Support (PBS) plans were in place where necessary. We reviewed a person’s ABC chart in correlation with their care plan and looked at staff interventions and actions. Interventions that were included in care records, for example the person “responds well to a calm approach” and positive risk taking, was not always observed on the day of assessment. This raised concerns regarding the accuracy and effectiveness of managing risks in-line with people’s care records.

We raised this with senior leadership who told us following our feedback they had implemented intensive interaction training for all staff and had a behaviour practitioner visiting the service to complete observations of staff interactions with people and provide additional support. Senior leadership told us PBS plans and ABC charts had been updated to accurately reflect current needs following our site visit. Yet, feedback from some staff indicated these interventions had been ineffective in managing risk, therefore we were not assured by the actions implemented.

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

The service had an up-to-date personal emergency evacuation plan (PEEPs) in place for all people living at the care home. The environment had adaptations and reasonable adjustments in place to help meet people’s individual needs. However, the service did not always detect and control potential risks in the care environment. For example, we saw a drawer in the kitchen was labelled ‘Knives must be locked in the kitchen drawer at all times.’ The drawer was unlocked and there were 2 pairs of kitchen scissors and a large knife. We pointed this to staff who then locked the drawer but the second drawer did not have a lock but had 3 knives, a pair of scissors and an array of screwdrivers that were easily accessible to people living at the service. According to people’s individual risk assessments, these items must be locked away to ensure the safety of all people living at the care home.

Additionally, 2 people’s wardrobes were not safely secured to the wall in their bedroom posing a potential risk of injuries and falls. We requested for immediate assurances and the service responded promptly to concerns and provided us with assurances that these have been resolved.

Some relatives we spoke with were positive about the quality of the care their loved ones were receiving. Comments included: “Every time I visit, he appears happy,” he is “well looked after, adequate staff on,” and that the service had “4 absolutely brilliant staff.” However, some relatives raised concerns about staffing levels. Comments included: “high turnover of staff,” “not enough staff,” and expressed concerns with supporting people to access the community, they “do not really get out much because of staffing.”

The service made sure there were enough qualified, skilled and experienced staff, however they did not always make sure staff received effective support. The service had a service manager in post who was undergoing registration with the Care Quality Commission (CQC). The service manager confirmed there were 4 staff on duty during the day and at night 2 waking and a sleep-in member of staff. We reviewed the duty rota over a 2-month period. This correlated with the service’s dependency level at the time.

We checked 2 staff recruitment files and saw that all appropriate processes and checks were in place. The service conducted enhanced disclosure and barring service (DBS) checks, which provided information including details about convictions and cautions held on the Police National Computer. The information helped the service make safer recruitment decisions. Supervision records showed all staff had regular supervision meetings with the service manager; however, supervision records were generic and not person specific in addressing further training, support or learning.

Staff received training the provider considered mandatory and there was a staff handbook and induction checklist in place for all new starters to support them in their role. Training records showed that staff received ongoing training that was appropriate for their role.

The service did not always assess or manage the risk of infection. The premises appeared generally clean. The service had cleaning audits in place and all staff had completed infection prevention and control training according to the training matrix. However, on the day of our visit, we observed that infection control and good cleaning practices were not being consistently followed in line with protocol. For example, there was a spillage on the floor and a staff member was observed cleaning it without using the appropriate cleaning and safety equipment. We raised this immediately with the service manager who took action to resolve this on the day of assessment.

The service did not always make sure that medicines were managed safely. there was no process in place to receive and act on medicines alerts and there was a box being used as a controlled drugs cabinet. This did not meet legal requirements. Controlled drugs must be stored in an appropriate cabinet that is bolted to the wall to meet regulations. We raised this with the provider who took appropriate action to resolve the issue.

Records we checked showed people were receiving their medicines as prescribed. Medicines were stored securely and at the required temperatures. Medicines care plans and protocols where people were prescribed medicines to be given as required (PRN), were in place to help staff understand and support people with their medicines. The staff received training and were competency assessed to handle medicines safely. Staff were aware of the principles of stopping over medication of people with a learning disability and autistic people (STOMP). Medicines were not used to control people’s behaviour.

Staff carried out audits to identify gaps and make improvements. Medicines reviews were carried out by the clinical pharmacist from the local GP practice. There was a medicines policy in place.