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 inadequate. At this assessment the rating has changed to 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.

The service was previously in breach of the legal regulation in relation to; Safe care and treatment relating to the safe management of medicines. Enough improvements had been made at this inspection, and the service was no longer in breach of this regulation relating to the safe management of medicines.

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, and staff did not always listen to concerns about safety or consistently investigate and report safety events. Lessons were not always learnt or embedded in practice.

Whilst we saw signs of progress, the provider had not yet established or fully embedded a robust learning culture, as shown by communication gaps with relatives and inconsistencies in daily records and audit completion across both locations. However, the service had taken meaningful steps towards improvement. Leaders had introduced more structured learning forums, including team meetings that focused on safeguarding escalation, medicine themes, punctuality and the quality of Nourish recording (Nourish is the providers electronic care planning system.

Staff reported greater confidence in raising concerns and described recent knowledge sharing sessions on MCA/Best Interest decisions, investigations, recruitment processes and quality expectations as helping them understand and apply safer practice more consistently. Incident data recorded was being reviewed and discussed, with managers beginning to use trends to inform supervision and practice sessions on MCA/Best Interest decisions, investigations, HR processes and quality expectations as helping them understand and apply safer practice more consistently. Although this reflected clear progress, further work was required to ensure learning was consistently embedded and sustained across all staff and shifts, so that the safety culture became reliably proactive rather than reactive.

The provider had not always ensured safe systems of care, and previous inspections had identified gaps in risk management, medicines safety and the continuity of support when people’s needs changed. However, recent improvements showed that systems and pathways were becoming more reliable and better monitored. At both supported living settings, leaders had strengthened routine governance through tiered audit systems, medicines checks, daily health and safety reviews and incident tracking, which enabled earlier identification of concerns such as medicines discrepancies, environmental risks and gaps in daily recording. However, these processes had not always identified some of the issues we found during our visits.

People’s care records had recently transferred onto electronic systems and contained clearer guidance on clinical and behavioural risks, including choking risks, epilepsy care, PBS (positive behaviour support) strategies and step by step support for complex routines, helping staff maintain continuity and consistency during handovers and transitions. However, information was not always consistent across paper records held alongside.

Managers worked proactively with external partners such as consultants, speech and language therapists (SALT), social workers and commissioners to support safe transitions and ensure responsive updates when people’s needs escalated, including community DoLS applications, epilepsy monitoring reviews and health appointments.

The provider did not always work well with people or healthcare partners to understand what being safe meant to them or how best to achieve this. 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 or neglect, and concerns were not always shared quickly or appropriately.

During our assessment we found 2 occasions where the provider failed to notify CQC of incidents that had occurred within the services; however, these incidents had been reported to the relevant local authorities, and during our assessment 1 of the statutory notifications were subsequently submitted retrospectively to CQC by the service manager.

Staff we spoke with told us they had received safeguarding training and were aware of how to escalate concerns both internally and externally. One staff member explained they would report safeguarding concerns immediately to the manager and, if needed, escalate to the area manager or local authority, demonstrating clearer knowledge of appropriate routes. Despite this, practice was inconsistent, and wider safeguarding concerns were not always managed in a timely or transparent way, for example, families described delayed communication, and other safety events, which reduced their confidence in safeguarding responses. Leaders had recently taken steps to strengthen safeguarding systems, including reinforcing escalation procedures during team meetings, improving the quality and consistency of incident reporting, and reviewing and updating risk assessments where incidents have occurred.

These developments demonstrate a growing commitment to a more open and robust safeguarding culture, and with sustained focus, the provider should be able to ensure concerns are recognised, escalated promptly, and that people, relatives and external partners are consistently involved to uphold people’s safety and rights.

The provider had taken steps to involve people in managing risks, but this was not always done consistently or in a way that fully reflected their preferences, communication needs or best interests.

Care records contained more detailed, person specific risk information, such as behavioural triggers, communication needs, activity planning requirements, and clinical risks including choking, epilepsy and physical health factors, which helped staff tailor support and reduce avoidable harm. People were also supported to make choices within structured routines through tools such as visual supports, activity prompts and guidance for daily tasks, promoting safer decision making while maintaining independence.

However, relatives reported that risks were not always consistently managed or clearly communicated, including delays in being informed about incidents, concerns about nutrition and weight management, and inconsistent approaches to supervision and accessing the community, which affected their confidence in how risks were balanced in day-to-day practice. today practice.

Leaders had strengthened how risks were reviewed and shared across teams using ABC charts, daily handovers, incident trends and updated risk assessments to improve consistency and ensure staff had clearer, real-time information to guide safe decisions. Continued focus was needed to ensure all people, and their families where appropriate, were routinely involved in risk discussions so that risk management remained collaborative, transparent and focused on enabling people to do what mattered to them safely.

The provider had not always detected and controlled potential risks in the care environment, and they did not always make sure equipment, facilities and technology supported the delivery of safe care.

Environmental audits showed that risks were not consistently identified or acted upon, including gaps in monthly compliance checks and incomplete action logs, which reduced oversight of potential hazards. We also found that facilities were not always maintained to ensure safe use for example, a shower had been out of action for an extended period, resulting in a person having to use a neighbour’s facilities, and this issue had required repeated escalation to the landlord for repair.

Despite these issues, service managers and the supporting senior leadership team had increased oversight through more regular daily health and safety checks, audits and environmental reviews, and staff could explain how they reported hazards and escalated maintenance concerns appropriately.

Continued focus was needed to ensure environmental risks were consistently identified, addressed promptly and monitored so that the environment and equipment reliably supported safe care.

The provider was continuing to strengthen staffing arrangements, although further work was still needed to ensure all staff consistently had the skills, experience and support required to deliver safe, high-quality‑quality care.

Safe recruitment processes were followed, with new permanent staff completing full pre‑employment checks, including DBS clearance, before starting in post. Relatives confirmed that people were consistently supported by staff and that current staffing levels were not impacting safety or access to essential care, such as medicines and health appointments.

Staffing levels and competencies had previously been inconsistent, with gaps in oversight and variability in how teams worked together to deliver safe, person‑centred care.

However, during our assessment at 1 location, we found only 2 completed agency/temporary worker induction forms out of the 18-agency staff who had worked in the service, despite the provider’s policy requiring a completed induction form for each worker; we requested the remainder to be sent to us as they could not be located on the day. We were only sent 1 induction form which we had previously reviewed at the service.

Despite these concerns, there had been notable improvements. Training completion rates had increased, and induction processes had been strengthened, including access to specialist training tailored to people’s needs. Supervision had also become more consistent, with staff confirming they now received regular supervision, knowledge sharing sessions and competency-based discussions that helped them feel more supported and confident in their roles. Leaders had also reduced agency reliance and recruited additional permanent staff, including drivers, to improve continuity of care and ensure people’s commissioned hours were more reliably met. Although further work was needed to achieve full compliance with agency induction requirements and sustain consistent staffing across all shifts, these developments demonstrate improving workforce capability and a stronger foundation for delivering safe, effective support.

The provider had appropriate infection prevention and control arrangements in place, and staff demonstrated awareness of safe working practices; however, these were not always applied consistently across both locations.

The provider’s PIR described a comprehensive IPC framework including policy guidance, PPE availability, staff IPC training, hand hygiene competencies, outbreak management processes and oversight from the health and safety team which showed an organisational commitment to maintaining safe infection control standards.

People and relatives reported that staff had access to appropriate PPE, and we observed PPE available within people’s flats, indicating that infection control measures were generally embedded in daily routines.

Some environmental issues such as delays in repairing essential facilities had the potential to undermine IPC standards; however, these maintenance responsibilities sat with the landlord, who was required to address them in a timely way. Ongoing vigilance was needed to ensure infection control processes were consistently applied, any environmental concerns to be escalated promptly, and that the physical environment continued to support safe and effective IPC practice.

The provider did not always ensure that medicines were managed safely and in line with best practice, and systems were not consistently robust across both locations.

We found examples of incomplete PRN protocols (as and when required medicines), discrepancies between MAR (medication administration record) directions and pharmacy labels, and 1 instance of expired topical medication still present in a person’s medication supply. This demonstrated a gap in stock rotation and oversight. Audits had not always identified some of these issues and audit outcomes were not always acted on promptly or recorded with clear evidence of rectification.

Despite this, many relatives told us they had no concerns about how medicines were managed, describing practice as safe and well communicated. One relative said, “They keep it in a locked cabinet now, I haven’t heard anything about any mistakes”, while another told us, “I’ve had no reports of or concerns about medications.” A third added, “I haven’t had any medication concerns… they always bring it if we meet and tell me how to give it to him.” These positive accounts were supported by recent improvements: medicines files were generally well organised, most PRN protocols were present, and staff had access to clearer guidance for administering regular and PRN medicines.

Leaders had strengthened governance through more frequent audits, enhanced oversight of stock levels, and reinforced escalation processes during staff meetings, and improved training and competency checks to increase staff confidence in safe medicines practice. While further work was required to ensure all medicine records were complete, protocols were updated, and audit actions consistently closed, the increasing stability of systems together with positive feedback from relatives demonstrated that the provider was moving toward safer, more reliable systems to support effective medicines optimisation.