Social Care Solutions (Rothwell) Also known as Peartree Court

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 Good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 systems and processes in place for recording and reporting incidents. There was evidence of accidents and incidents being reported by staff and oversight from the registered manager and provider.

The registered manager told us they reviewed themes and trends as part of the review of each incident that took place. We saw evidence of learning and outcomes being recorded against each individual incident.

We looked at a recent medicines error the provider had told us about on a statutory notification. The provider had sought medical advice once the error had been identified and had reported the concern to the local authority. We also found local medicines practice had been modified by the provider to mitigate the risk of recurrence.

The provider had a system for provider oversight of all accident and incidents at the service and although the use of this locally was developing, the registered manager told us they would be using this to review overall themes and trends for the service moving forwards.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However, they did not always make sure records supported continuity of care, including when people moved between different services.

The provider had systems, processes and policies in place to aid safe systems, pathways and transitions. For example, we saw evidence that a pre-admission assessment was completed prior to people moving into the service. As part of the pre-admission assessment a risk screening tool was also completed.

The registered manager told us that although pre-admission assessments were completed by an enquiry, referral and assessment manager they had been part of the assessment for people moving into the home. The registered manager assured us that although assessments were completed by a support function, they had the ultimate signoff in relation to meeting the individuals’ needs before admission.

There was an emergency pack available to support the smooth transition to other services, including hospital admissions. We found that emergency packs did not contain all the required information to support safe admissions. For example, one emergency pack we viewed did not detail the mobility needs for a person, including the requirement for staff to use a hoist for all transfers.

The registered manager told us during the assessment, they had found people’s support plans had not been linked correctly to the emergency admission pack and that team leaders were reviewing these to ensure records were complete.

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. The provider shared concerns quickly and appropriately.

The provider had safeguarding policies and procedures supported by systems and processes to record safeguarding concerns. The registered manager demonstrated the recording process from inception of an allegation through to closure.

People told us they felt safe living at the service. This was supported by relatives who told us their family felt safe being supported by the provider. For example, one relative told us, “[Relative] feels safe with staff.” Another relative told us, “[Relative] tells me they feel safe.”

Staff completed safeguarding training and demonstrated an understanding of safeguarding and how to report concerns. For example, a staff member told us, “I would report any concerns to my team leader or manager, but I know we can also tell safeguarding or CQC.”

Staff demonstrated awareness of Deprivation of Liberty Safeguards (DoLS).

The provider did not always make sure risks were reflected in risk mitigation plans. However, staff understood people’s needs and risks and were able to articulate the action they would take to mitigate these.

People and their relatives were involved in decisions about managing their own risks. People were encouraged to take positive risks to encourage accessing the community or developing their independence.

Although generally risk assessments showed how people were supported to manage their risks and these provided staff with guidance. We found some risk assessments required further guidance. For example, risk mitigation plans for constipation.

Staff demonstrated a good understanding of supporting people to manage their risks. A staff member told us, “We work with people to manage risks – we try to give them as much information to help them make a decision in relation to safety.” Another staff member told us, “We talk people through their risks. Checking with them they understand why there is a risk is important. Involving external professionals, parents and relatives is important.”

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 living at the service had a tenancy agreement with a housing provider and were supported by the provider to maintain their tenancy.

The communal area and office were dated and required redecoration as well as a replacement carpet in the office. The registered manager told us the service was due a refurbishment and were awaiting plans from the housing provider.

The provider told us during the assessment the office was the provider’s responsibility, and a business case would be submitted for approval through their senior leadership team to get this decorated and the carpet replaced.

The provider had health and safety policies, and regular checks were carried out by the staff team. For example, we observed a weekly fire test being carried out that was led by a person living at the service, and we saw evidence of a service user taking part in health and safety checks.

The housing provider had not supplied the support provider with all records relating to health and safety. For example, the annual fire risk assessment review record was not available, and there was no evidence of the action that had been taken in relation to a failed emergency lighting service.

A staff member also told us a fire door had been defective since January 2025 and despite regularly following this up with the housing provider no effective action had been taken. The registered manager escalated these concerns internally within the support provider during the assessment.

We were not assured the support provider’s internal escalation processes were always sufficient to support people to control potential risks to their environment.

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.

Staff were recruited safely and in line with the providers safer recruitment practices.

We saw evidence of the provider’s corporate induction and the local induction when staff commenced their employment. Staff told us they received enough training to safely deliver care and support for people although a staff member told us, “There could do with some improvement when doing medicined shadowing.”

The provider had a range of mandatory and service specific training. For example, specific training was arranged for cerebral palsy, diabetes, learning disabilities and autism to make sure staff could meet people specific needs.

Feedback from staff, people and relatives confirmed there was enough staff on shift to meet people’s needs. Rotas generally confirmed this. A relative told us, “There is always plenty of staff when we visit. We have no concerns.”

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

The provider had infection, prevention and control policies. 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.

People were supported to keep their flat clean and tidy and we found these were maintained to a high standard. Staff kept records in relation to food hygiene, including food temperature checks and labelling open food although not all food was labelled.

The provider had medicines policies, and we found daily medicines temperature checks were being recorded by staff. Staff administering medicines had completed medicines training and received adequate competencies.

We found that medicines practice was generally safe and medicines were administered as prescribed. However, we found that the provider had not implemented their count sheet for some medicines since the new medicines cycle had commenced.

We also found that a prescription label was ambiguous and needed further clarification. There was a constipation medicine that was in stock, however, these were not prescribed on the MAR [medicines administration record] and another constipation medicine that was on the MAR was not in stock.

We found that where ‘as required’ medicines [PRN] had been administered, staff had not recorded if the medicine had delivered the desired effect on the electronic monitoring system.

A team leader told us they would contact the GP to clarify the prescribing instructions for the concerns we raised, and the registered manager assured us they would address the concerns we had identified.