Peartreelifecare Limited

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 supported living 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 59 (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.

The provider did not consistently demonstrate a learning culture that supported safety. While managers described sharing learning through team meetings, daily handovers and newsletters, this was not always effective in identifying and addressing risks. Audits and governance systems had not identified several issues found during the assessment, including concerns relating to medicines management, infection prevention and care documentation. Safeguarding records did not consistently capture lessons learnt, limiting assurance that learning was embedded. Some relatives told us they raised concerns repeatedly without seeing improvement, one person told us, “Nothing comes of the safeguards. It’s unacceptable.”
The provider showed an understanding of the need to learn from incidents and feedback. Systems were in place to review incidents, audits and complaints, and leaders discussed learning with staff.
 

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.
The provider had systems in place to support safe pathways, transitions and continuity of care. Pre admission assessments were completed, and managers told us they ensured sufficient trained staff were available before accepting new care packages. We saw evidence of communication with hospitals, local authorities and health professionals before and after hospital discharge. Relatives described meeting staff prior to care starting and being given information about how care would be delivered. These arrangements helped reduce risks during transitions, although involvement of people and relatives was not always consistent or well evidenced.

They did not always concentrate on improving people’s lives.
The provider had arrangements in place to safeguard people from abuse and avoidable harm. Staff completed safeguarding training and demonstrated an understanding of how to recognise and report concerns, including the use of internal and external reporting routes. Policies were in place, and safeguarding notifications were submitted to CQC as required. Managers understood their responsibilities under the Duty of Candour. However, safeguarding logs were not always fully completed, including gaps in recording outcomes and lessons learnt. Concerns raised by relatives during the assessment were escalated promptly. Overall safeguarding systems were in place, however, recording and learning required improvement.

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.

People and their relatives were not consistently involved in managing risks to their safety. Risk assessments were in place, including for falls, flammable creams and skin care, but some lacked sufficient detail to guide staff practice. Care records did not consistently evidence how risks were monitored or reviewed, for example catheter care documentation did not always record required observations. Relatives told us they shared information about triggers and risks but felt this was not always acted upon, with one saying “They don’t listen to me. I have tried guiding them”. This limited assurance that risks were jointly understood and managed.
 

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.

The provider did not consistently ensure people were supported in safe and well maintained environments. Safety checks such as gas, electrical and water temperature monitoring were up to date, and environmental certificates were in place. However, during the assessment we identified several environmental risks, including missing window restrictors, garden hazards, and mould in a kitchenette. While some the provider had identified previously and actions were taken during this assessment, the number and nature of issues indicated that risks were not always identified or addressed promptly through routine oversight.
 

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.
The provider had arrangements in place to ensure people were supported by enough suitably skilled staff to keep them safe. Recruitment gaps had been identified and were being actively managed; however we identified some gaps in recruitment history that required further investigation, this was discussed during this assessment. Managers told us they did not accept new care packages unless there were sufficient trained staff available to meet people’s needs safely. Competency assessments were completed, and professional revalidation dates were up to date. Clinical oversight was provided by registered managers with nursing backgrounds, supported by a learning disability nurse and Abbot nurses. Staff received regular supervision, appraisals and spot checks, which supported oversight of practice and performance. Staff told us they felt supported by management and were able to access training and guidance when needed.
 

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.

The provider had systems in place to reduce the risk of infection. Staff completed infection prevention and control training and had access to personal protective equipment, which we observed being used appropriately. People’s homes were clean and free from odours. However, we identified some shortfalls, including food items, increasing the risk of contamination. These issues were discussed and addressed during the assessment. Oversight arrangements were in place but required more consistent application to ensure sustained compliance.
 

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.
Medicines were not consistently managed safely. Although most medicines were administered as prescribed and staff had completed relevant training, we identified several governance shortfalls. These included unprescribed medicines in storage, out of date blood glucose strips, and missing opening dates on creams and sprays. Medicines cupboard temperatures were not monitored until raised during the assessment. These issues demonstrated that medicines oversight and auditing were not effective. However, the provider took steps during this assessment to strengthen their medicines audits.