Social Care Solutions (Raunds)

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 service. This key question has been rated 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.

This service scored 53 (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.

The provider had policies and procedures for recording and reporting incidents. A record of accidents and incidents was reviewed during the assessment. We found some incidents were changes in a person’s emotions and work was required to review how these were recorded.

We were provided with some evidence of learning activity at the service through records called sharing good practice to improve quality and safety. However, this learning and sharing did not relate specifically to safety events and there was no evidence provided of an analysis of incidents to consider triggers, themes, and trends across the service to improve people’s experience.

The interim manager did not initially have access to the records on the system for the service, and although they assured us they were reviewing any incident on paper, this meant they did not have access to previous reporting records, or historical incident data. This was addressed by the provider at the beginning of the assessment.

The provider did not always work well 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.

There was an emergency pack available to support the smooth transition to other services, including hospital admissions. We found some conflicting information in the document relating to a person the service supported. For example, on the front page of the emergency pack this stated, “A DNACPR is automatically put in place by the hospital". However, this statement was not correct and was contradicted in another section of the emergency pack that said, "[Service user] Does not have a DNACPR in place”.

Although staff demonstrated knowledge of the person’s resuscitation status, the contradicting information meant the documentation that would be passed to professionals if the person’s health deteriorated, or in in an emergency, may cause confusion or an inappropriate treatment plan.

The provider did not always work well with people and 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 had safeguarding policies and procedures. Staff completed safeguarding training and demonstrated an understanding of safeguarding and told us how they would report any concerns. However, we were not assured that staff always recognised the importance of taking action to prevent potential abuse. For example, we found there was no system for signing people’s pre-paid card out of the service by those staff responsible for accessing the monies. We also found that a person’s monies were kept in a cashbox in the office. The key to the cashbox was in this and the lock on the cupboard this was kept in was broken. There had been no action taken to mitigate the risk to the person’s monies. The Interim Manager told us this had been rectified after staff shared our feedback.

Although a Deprivation of Liberty Safeguards (DoLS) had been requested through the local authority we found there was a lack of understanding amongst the team in relation to DoLS and when a request should be made.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had a risk assessment and positive risk-taking policy. However, risk mitigation plans did not cover all known risks. For example, there was a lack of supporting risk assessments in relation to a person’s known risks relating to mobility, finance and health.

The provider has a positive behaviour support (PBS) policy. The service had implemented a PBS plan and a behaviors that challenge support plan. These records had not been triangulated and there was no evidence of a functional assessment or involvement of a PBS practitioner (internal or external) to ensure the PBS plan was effective.

There was no evidence people were supported to understand and manage risks. Shower temperatures were not always evidenced, so we were not assured this was always being checked during personal care.

The provider 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.

People were not always supported to keep their home safe and well maintained.

The provider had health and safety policies in place, and a range of health and safety checks were completed by the staff team. However, we were not assured all required checks were completed. For example, all flats are fitted with assistive technology,and although a person received support from a staff member 24 hours a day,there was no evidence that their emergency call bell had been checked. We were also not provided with any evidence of wheelchair checks for a person’s wheelchair and the checklist for cleaning had not been completed for the month of September.

A person’s support plan for behaviours that challenge states, “Staff must ensure these (cleaning chemicals) remain locked in [service user’s] cupboard”. We found the lock on the cupboard these were stored in was broken and no action had been taken to mitigate the risk.

During our out-of-hours visit to the service we found that a route from the back of the property to the car park was blocked with large interlocking foam tiles. This meant people’s evacuation during an emergency could be impacted.

A fire evacuation practice in September 2024 recorded it took 40 minutes to evacuate the building and a further practice in January 2025 recorded that not all people evacuated their flats. We were concerned there was a lack of learning and action taken to mitigate the risk to people.

A person’s emergency evacuation plan did not provide adequate information to assure us staff had the appropriate guidance to evacuate them from the home in an emergency. For example, there had been no consideration given to the person being in their bedroom and the need to evacuate via the back of their flat.

The carpet in areas of a person’s flat were worn and the person would benefit from support from staff to explore options for cleaning or replacement. We noted there were repairs required in other communal areas. For example, some walls require redecoration, and a door lock required replacement. The front pedestrian gate was noted to not always being closed and a contributing factor was the required repair.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs, and they did not always make sure staff received effective support to develop.

The provider demonstrated permanent staff were recruited safely and in line with the providers safer recruitment practices.

The provider demonstrated that there was regular supervision and appraisal taking place and this was confirmed by staff working in the service.

We found there was enough staff on shift to meet people’s needs and feedback from staff confirmed this. A staff member told us, “Yes, we have enough staff – there is always enough staff on shift.”

We found that staff had completed the required mandatory training for their role, and the provider had assessed the training requirements for the service to meet people’s specific health needs. For example, staff received Prader-Willi-Syndrome training to help them support a person living with this condition. However, we found one staff member who was lone working with the person with Prader-Willi-Syndrome had not completed this training. The interim manager told us the staff member had been registered for the course, and they would prioritise the completion.

The rotas in the service we viewed indicated a person receiving personal care had been assigned agency workers. The interim manager assured us this was an administrative process, and due to the person’s complex needs the agency worker would be swapped with a permanent member of the team on arrival. However, there was no process to confirm the name of the staff member who had worked with the person without reviewing daily records. Although the manager assured us that agency workers would not be allocated to this person, and they provided us with evidence that a regular staff member had been allocated for the rota's we viewed. We were told by staff there had been occasions where agency workers had supported the person. Work was needed to ensure there was a robust governance process in relation to evidencing the deployment of the staff team, as the rotas we viewed were factually inaccurate.

We viewed the processes that were in place in relation to the use of agency workers at the service and found those deployed did not always have evidence on their profile of learning disability and autism training to the Oliver McGowen standard. We also found there was not always evidence of a DBS, a photo, or an induction to the service. We were therefore not assured by the provider’s systems and processes to ensure agency workers were safely recruited and inducted into the service.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection control policies were available. Staff had received training in infection prevention and control and told us they had access to personal protective equipment (PPE) such as gloves and aprons to prevent the spread of infection.

We observed that PPE was not always discretely stored in a person’s home and recommended to the leadership team that storage options were considered to ensure a homely environment was maintained free from equipment needed by the staff team.

We found staff were completing food hygiene records, including temperature checks for hot and cold food, checking expiry dates and labelling open foods.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider demonstrated that all staff administering medicines had completed medicines training and received the required competency assessment.

We found that not all as and when required medicines information[PRN protocols] or creams and lotions records [TMAR] had adequate information for staff to be able to safely administer ‘as required’ medicines. For example, the agreed reason for applying a cream given on a person’s protocol was “To manage and control breathing”. This was incorrect, we raised this with the interim manager who took action to address this during the assessment and shared updated protocols.

Medicines temperature checks were being recorded by staff. However, we found some temperatures had not been recorded daily, and on one occasion, where the temperature had exceeded the recommended maximum, there was no evidence of action being taken to mitigate the risk of medicines becoming spoiled or ineffective.

We found some medicines were being kept in a cupboard in the office. During our assessment we observed the lock was broken and medicines were not secure. Although the interim manager arranged for this to be fixed the following day, we were not assured staff recognised the risk this posed, as no action to mitigate the risk of medicines not being secured had been taken.