Social Care Solutions Ltd (Herts & Bucks)

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 good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to; Safe care and treatment relating to the safe management of medicines

This service scored 38 (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 in a timely manner. There was a lack of oversight and analysis of incidents, particularly those which had occurred where people were most reliant on staff anticipating their care and support needs due to their vulnerability. Lessons learnt and information sharing was not consistent to continually identify and embed good practice.

Learning from incidents was not consistent across both supported living settings. At 1 supported living setting they were unable to demonstrate how lessons were learned from incidents which had taken place. For example, we found there had been a medicine error made which resulted in the regional director requesting all staff to retake their medication training However, staff continued to administer people’s medicines daily as there were no additional trained staff to administer people’s medicines whilst this training was being completed. The leadership teamwere unable to demonstrate any reflective practice, or discussions were undertaken to identify any lessons learned and how to mitigate the risk of future reoccurrence for incidents which had occurred.Despite this the interim service manager at another supported living setting printed their lessons learned from incidents and kept them in a folder, they told us, “We have discussions in team meetings, work chats on how we can improve or in 1:1 supervision. I am writing the lessons learned form and staff will need to sign to say they have read and understood this. We also share information by using our communication book.”

The majority of people and relatives we spoke with knew how to raise a complaint or a concern. However, we received mixed feedback relating to the outcomes of incidents reported to them. Comments included, “There was an incident last year which should have been recorded in the book. The manager at the time phoned me because there was nothing in the book and they called safeguarding and told staff to check morning and night and organised the retraining of staff, I was satisfied with the response.” And “I think the care is safe now. However, there was an incident a while ago, which we never got to the bottom of it."

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. People had hospital passports in place so information about them could be shared between services when needed. However, not all were current or had been reviewed regularly so did not demonstrate information about how to support people appropriately to improve their experience when moving between services was accurate. When people moved into their new home, there was a lack of planning to ensure a smooth transition. Documentation did not show how involved the person, their family, staff, and relevant professionals, were to ensure a collaborative approach. We found people were not gradually introduced to their new home, allowing them adjustment time and to become comfortable. A member of staff told us, “We have had 3 new people, 1 person moved in, there should be a transition period, and we struggled so they had to be moved. The transitions here are not as detailed as they should be. I think they are forced to accept what is there.”

The provider 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 majority of people and/or their relatives did feedback that they or their family members were safe with staff and felt they received safe care. One person told us, “I feel absolutely safe here,no one can get in without staff asking who they are.” A relative told us, “We have never had any concerns about the people who look after [person], and we go every week.”

Systems and processes were in place to safeguard people from abuse. However, investigation reports were not always readily available for review or not provided when requested. Not all staff felt confident concerns they raised to their service manager were taken seriously by the higher senior leadership team and not all staff were aware of whom to escalate concerns to outside of the organisation. This information was shared in the feedback provided to the managing director who advised a new area manager was about to commence in post on the 23 June 2025 and would be supporting both supported living settings to make the required improvements to the quality of care and support.

The provider did not 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 had support plans and risk assessments in place, however some people’s support plans and identified risks had not been regularly reviewed or updated. Information was out of date and no longer current, although the local authority had highlighted this as an area of improvement for 1 of the supported living settings in their last audit published February 2025. We found very little progress had been made in this area with little or no provider support. Only 1 care plan out of 7 had been transferred over to a new electronic care planning system during our assessment site visits. The manager told us this had taken 1 month to transfer the information in between the day to day managing of the service and was not confident they would meet the agreed action plan time frame for the end of June 2025. As a result, there was a lack of effective systems to ensure continuous improvement and the consistent monitoring of outcomes. This gap in practice is particularly concerning given the inherent vulnerability of people with learning disabilities and/or autism. Furthermore, positive outcomes for people were not always clearly recorded. This limited the ability to track progress towards personal goals and to demonstrate improvements in people’s quality of life. The regional director advised support was being sourced internally and had been agreed, and meetings were about to take place to agree support dates and times.

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. Whilst the inspectors were visiting one setting, a person was observed to be lying on the communal hallway floor for 20 minutes. During this time, we observed no interaction with the persons 1:1 support staff, this is a member of staff allocated to be with a person at all times, nor were they visible in the communal hallway. The inspectors came across an unlocked door which posed a potential risk to vulnerable people being able to leave the building alone in the event of their 1:1 support not always being present. A similar concern had been raised the previous month. This related to the vulnerability and safety of people living at the service and a person’s 1:1 support staff member not in attendance, which posed a potential risk of person(s) being able to leave the building unaccompanied placing them at potential risk of harm.

The provider did not demonstrate there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. People had the appropriate number of people to support them as was determined by an assessment of their needs, but this did not always consider their skill mix and experience. Staff support, supervision and development opportunities were inconsistent across both supported living settings. Staff comments included, “It has been about 12 months since my last supervision”, “We have supervisions every 6 months. Staff meetings are not regular so would be better if they were more frequent. Over the years I have been here, we have gone through too many managers, they barely stay very long. If the management team is effective, it is a brilliant place to work.” And “Now staffing levels are quite good and it is very stable, however I had no induction into my new role. The manager is very busy, trying to help me as much as possible but I think there should be a proper induction.”

Staff told us they undertook a range of training relevant to their role. However, we received mixed feedback from staff relating to the quality of training which was now being completed online. Comments included, “Initially we used to go to [another branch] for training and did more face to face.... There is not enough practical training. We did Manual Handling training recently and a lot of the staff had never done the practical.” And “I have been here 2 years now. I had my induction for 3 weeks and completed the eLearning. We get refresher training and are prompted to complete the courses. The training is good and helps to create an awareness how to support people better. It also increases my confidence.”

The provider carried out a range of recruitment checks on staff to help ensure they were suitable. New staff undertook an induction and training, which included training to understand about the needs of people with a learning disability and autistic people. However, when we reviewed the staff training matrix’s for both supported living settings, we identified gaps where staff had not yet completed several of the specialist training subjects which reflected the needs of people, they were actively caring and supporting. For example, subjects such as EpilepsyAwareness, approximately 69 members of staff across both settings over 50% had not yet undertaken this core subject. Similar gaps were noted for Diabetes training where 1 supported living setting only 2 members of staff out of 37 had completed it. The regional quality manager informed us they had identified a number of gaps which as part of a lessons learnt at an ongoing regulatory inspection elsewhere, all staff had now been assigned this training, and they had an action in place to complete this by the end of the June 2025.

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 majority of people and relatives we spoke with did not raise any infection prevention and control concerns. Comments included, “The house is immaculate, not sure about PPE or hand hygiene; however, [person] has never picked anything up,” “Staff use PPE and observe hand hygiene, everything is very clean.” And “Staff support me with washing and dressing and prompt to keep my flat clean and tidy.” PPE was available for staff to use when required. Staff had undertaken Infection prevention and control training.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in reviews of their medicines. We found 1 person was being administered their medicine covertly, this is when medicines are being administered to a person without their knowledge. This method of administration requires appropriate authorisations to be in place, with input from the person, their legal representative, pharmacy and GP.

Staff had not identified a person may require the need for a laxative medicine even when staff had documented for a period of 10 days the person was constipated. The inspector had to request a follow up with the persons GP. This process took the manager a further week to arrange for an appointment with GP to request a prescription for a laxative medicine PRN ‘as required.’ The impact of constipation for people with a learning disability is a known risk and can result in serious illness and in some cases death.

Another person had a 0 balance of their medicine. The manager told us this was a trial for 1 month, however had failed to ensure a follow up review had been made prior to the medicine running out. The inspector had to request the manager follow up with the person’s GP for further review as suddenly stopping this medicine can lead to withdrawal symptoms such as dizziness, mood changes, irritability, anxiety, headaches, and confusion.

Counts of 3 people’s medicines at 1 supported living setting failed to reconcile. One person was found to have been administered medicine 8 months after it’s expiry date. Auditing processes had not been undertaken consistently and the most recent audit undertaken by the regional director on the 26 May 2025 had failed to identify the issues we found on the day of our assessment visit.