Pickworth House

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. This is the first assessment for this registered service. This key question has been rated as good, meaning people were safe and protected from avoidable harm

This service scored 78 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The provider had developed a philosophy of care that promoted a culture of honesty, understanding and responsibility. Daily and weekly mangers meetings were held to discuss topics such as visitors to the service and scheduled appointments for people. Staff were given opportunities to identify risks and reflect and learn when things went wrong. They used a ‘no-blame’ approach which offered support and reassurance.

An annual staff survey and monthly supervisions ensured staff felt listened to and had opportunities to discuss well-being concerns, which the provider then acted upon. The staff team shared information and best practice with local services such as the Community Forensic Team (CFT) and the Lincolnshire Integrated Care Board (ICB) to minimise the risk of developing a closed culture. This practice helped to better support people by working collaboratively to minimise risks and try to keep people safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People were happy with the transition process when they moved. The providerensured continuity of care with aims for people to live independently within the community. This ensured they had good oversight and promoted open, partnership working when planning and delivering care centred around people's needs in line with mental and physical health conditions.

A healthcare professional told us, "The staff have always been highly professional, they provide significant levels of support to the people. The communication with me has been very regular and information is shared as appropriate.”

People were fully involved in all assessments, supported to have a voice and to lead a life that they wanted. Staff promoted people’s rights by educating people about how to stay safe and access the community. The service offered places for people to stay on a long or short-term basis with 1 person who still received low level staff support successfully living independently within the community.

There were processes in place to ensure people's needs were assessed before being admitted to the service, with training provided to the staff about the best way that staff could support people.

Pickworth House monitored various aspects of the service quality and outcomes electronically. This data allowed the management to have oversight on all aspects of the service and allowed them to manage risk and promote well-being.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We saw safeguard reporting information in forms of wall posters, printed documentation and electronic slide shows that could be displayed on monitors within the home for both staff and residents.

Staff worked effectively with people in the community focusing on reflective practices that aided people’s understanding on how they could live safely in the community. Through monthly meetings with other professionals, staff were able to work togetherto build on skills that would support people’s lives within the community.

People were informed of any restrictions due to the conditions of their placement. Staff took time to discuss and to work with each person on an individual basis to ensure that any conditions were understood in line with living in the local community such as illicit drug use while living within Pickworth House. With the support of staff and keeping in line with their conditions, people were involved and supported to make choices and decisions for themselves on how they would like to live.

Staff demonstrated how they would identify and raise a safeguarding issue and had a good understanding about the importance of protecting people from the risk of avoidable harm, abuse or discrimination. They were able to identify different forms of abuse how and to whom it could be reported. There were procedures for staff to follow if they had any concerns about abuse including an anonymous email account for sharing concerns.

Restrictive practices were reviewed within the service my all-staff members. One person moved to Pickworth House under an Imprisonment for Public Protection (IPP) licence, which included specific conditions that they were required to follow. The individual demonstrated and understood the conditions of the IPP and the importance of adhering to the licence conditions. Through consistent work and engagement with the support staff and their probation officer, the risk was changed from medium to low. The individual and the Pickworth House staff team were currently working towards these conditions being ended in December 2025.

A person told us, “I work well with all the staff. At first, I thought it was a hospital and didn’t know what I could or couldn’t do here, but they were very clear and it’s now my home. I feel very safe living here.”

Staff told us they had received training on safeguarding adults from abuse, and they felt confident any concerns they raised would be managed appropriately.

There were systems and processes that protected people from avoidable harm. Risks to people’s safety and well-being were assessed and planned for with people having individual risk assessments in place. Each person’s support plan allowed staff to identify individual needs, the agreed goal to be achieved and the interventions required to achieve the goals. The management and support team kept oversight of risks linked to people's care though the regular review of care plans and risk assessments with collaboration from other professionals.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Through 1:1 support sessions staff and people were able to identify potential risks and how they could be supported to live a less restrictive lifestyle. This was achieved by having processes in place to promote a healthy lifestyle while working to minimise the potential risks involved.

Staff empowered people by supporting them to take positive risks, whilst at the same time remaining safe. An example involved a person wishing to stay over night with family in a different city. Pickworth House staff, with the support of social workers, discussed the potential risks and agreed this could take place. Staff members were successfully able to support the person with the overnight stay 3 times with the 4th stay being planned at the time of the assessment. This was a positive outcome building stronger relationships with staff, people and their families while providing independence and risk ownership to people. A second example involved a person being supported to manage their finances independently. Prior to moving into the service they did not have access to their own bank account and would be supported by family members due to money being a fixation and causing anxiety, resulting in a risk to their well-being. The staff at Pickworths worked with the person over many months, educating them on budgeting and the processes involving with incoming and outgoing funds. Currently money is no longer a trigger for them and they can spend their money confidently and without risk.

People told us they felt safe. Their comments included, "I feel safe in the home and in the local area. I know where staff are always, and I have the phone numbers for the home if I needed help.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The management team carried out regular workarounds and dealt with any concerns promptly. Staff completed routine health and safety checks, including fire safety, trips, falls and equipment servicing. Any issues were logged onto a data base that could be viewed by all appropriate staff and could be escalated to maintenance and acted on quickly.

We observed a calm and welcoming environment that supported people’s safety, mental health and promoted their independence. For example, on person told us how they were happy having their own en suite bathroom, allowing them to keep personal toiletries and belongings within the bathroom.

The service incorporated an electronic visitor sign in system. By using an electronic tablet staff were able to store the details for future reference appropriately. Information could be stored securely, ensuring that all information was legible, visitor photos were taken on arrival, and the information could be reviewed and accessed by senior staff via other devices.

Personal Emergency Evacuation Plans (PEEPs) were in place for each person using the service. Emergency signage was visible. Staff knew the evacuation procedures and described them confidently when asked, with the provider having appropriate plans in place to evacuate people in case of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People shared positive feedback about staff numbers and how responsive staff were to their needs. People stated they were able to have support anytime they needed, and activities and plans were never delayed or cancelled due to staffing numbers. The provider introduced twilight and waking night shifts that enabled people to take part in evening activitiessuch as attending live music and sporting events without affecting safe staffing levels. It was observed that between the months of August 2024 and July 2025 the service was not understaffed on one shift with the service providing safe staffing levels and at times having more staff than required on shift.

Pickworth House incorporated a robust recruitment process to ensure that fit and proper persons were employed. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out, previous employment history and information related to an individual’s physical or mental health conditions which were relevant to the person's capability, after reasonable adjustments were made.

Staff said that they felt supported and safe to do their duty. They received mandatory training relating to learning disabilities and sexual health relationships in learning disabilities. Staff training was reviewed annually with additional support provided if requested by staff or observed through staff supervisions with management. A staff member said, “The provider is able to offer the world in terms of training.” The provider funded, provided additional training time and support to staff who were pursuing additional role related qualifications.

The provider incorporated champions within the service, this gave the responsibility of certain aspects of the service to specific staff members. This involved staff undertaking additional training and support from leaders to lead on areas such as safeguarding, dignity, medicines and well-being. Additional plans within the service were in place to support staff to where they would be able deliver training to the team and the people.

We did not receive concerns from people and staff in relation to infection prevention and control.

We observed the service was clean and hygienic throughout and regular infection control audits were carried out. Toilets were clean and included soap, paper hand drying towels and working peddle bins. We observed electronic cleaning audits in place across the property with weekly bedroom audits that included maintenance alongside infection prevention control.

The environment was clean and tidy with personal protective equipment (PPE) such as disposable gloves and aprons available for staff use. There were systems in place to help prevent and control infections. Training records confirmed that all staff had received training on infection control. Staff were provided with personal PPE when needed and we saw they wore this appropriately.

A housekeeper was employed by the service to manage the cleaning of the home environment and deep cleaned each person’s bedroom once a week with support from people to promote their independent skills. Staff would support with these tasks throughout the week and the days when the housekeeper was not working.

Posters were visible regarding washing hands and colour coded chopping boards and utensils were used to prevent cross contamination in the kitchen.

Medicines were administered safely via a pre-packaged medicine pouch. These packages were sealed single doses that avoided the potential risk of medicine errors within the service. People received their medicines at the correct times in a way that was best suited them with two people self-administering their own medicine that was stored in a locked wall mounted cabinet in their bedrooms.

The service had safe systems for appropriate and safe handling of medicines. The provider refurbished a communal bathroom that was not used into a clinic room made for the service. This provided a private, protected space free of distractions for medicine administration including a sterile area for medicine reconciliation, improved infection prevention resulting in reduction in medicine errors since completion.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff discussed the medicine management process used within the home as an opportunity for people to understand their medicine better and learn new skills. People provided consent during the review process, kept informed and were included when their medicine changes occurred, staff supported people to be aware of and understand potential side effects and changes to medicine times.

One person told us, “I am taking my medication daily. I like to sit with the staff and we open the medication together and they explain what the medication is for and if there any side effects. I don’t have a problem with taking my medication as I know it’s good for me.”

The service was proud to mention that they do not use ‘as needed’ medicines within the home to support people who struggled with their mental health. Staff instead, used distraction strategies and emotional support to aid people. Stopping over medication of people with a learning disability and autistic people (STOMP) was incorporated within the service with staff being aware risks of the potential over prescribing of medicines. STOMP posters were witnessed within the clinic room and care plans reflected this.

Regular daily, weekly and monthly medicine audits were carried out. These covered areas such as daily medicine balances, safe medicines cupboard and fridge temperatures.