Kent PBS Service

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, safeguarding people from abuse and neglect and safe staffing.

This service scored 25 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was a poor learning culture within the service. Whilst there were systems such as multi-disciplinary meetings to discuss people’s needs and how their outcomes could be improved, these strategies were not clearly embedded in practice and people had a poor quality of life. Accident and incident reports were not detailed enough to allow robust analysis and we identified incidents of abuse or neglect that had not been reported. Despite people having ongoing complex health and care needs, their care plans were not consistently updated in response to incidents or events to reflect any learning taken. There had been significant poor practice recently identified by the provider in some areas such as around medication management, but at the time of the inspection that had not improved.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Stakeholders raised significant concerns about their engagement with the provider and how people’s care was managed in line with clinical guidance. One health professional raised concerns that when staff contacted them about a deterioration in a person’s health, they would often leave a different mobile number as the contact. This meant they were often unable to reach staff once they had gone off shift, resulting in potential delays in people receiving the healthcare support they needed. Other stakeholders shared concerns about staff knowledge and failure to embed strategies such as how to support people with personal care or to access to the community, despite significant involvement. Where people neglected themselves or placed others at risk of harm, it was not clear that the provider had made appropriate referrals to stakeholders around this to allow people to get the support they needed.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Where instances of abuse had taken place between people, leaders had not always consistently reported these as a safeguarding or notified CQC in line with their statutory responsibilities. This included instances of physical assault which had not been reported in a timely way which would allow an investigation to be undertaken by the local authority to ensure people’s safety.

People frequently self-neglected, including personal hygiene, nutrition and hydration and had engaged in activities that s placed them at significant risk. There was no clear evidence that people received appropriate encouragement to maintain their health and wellbeing. For example, one person had been assessed as requiring 2.5 litres of fluid per day in line with recommended guidance. However, their records showed they had consumed 1 litre or less on 6 occasions during the previous fortnight. . This placed them at significant risk of dehydration but there was no evidence of staff taking any action to reduce this risk or to recognise this self-neglect.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Where the risks to people were deemed sufficient that restrictions such as living in locked accommodation were needed, to ensure their safety, appropriate authorisations were sought and recorded.

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

Risk management was poor and exposed people to significant risk of harm. Poor staff knowledge and training increased this risk as staff were not always able to identify, assess or respond when people needed help. One person had a significant choking risk, however staff had not received any in person training and did not know what they would do if this person had a choking incident. One staff member stated they would give them water which was exceptionally dangerous, as this could push any blockage further into the airway and prove fatal.

We found that when people became distressed and agitated, staff did not always administer prescribed medicines promptly to help reduce their distress. This increased risks, resulting in avoidable escalation of behaviours and placing people, and staff at significant risk of harm. We saw one incident where staff had supported a person to get into a car despite being in significant distress and agitation, which placed them and staff at in danger by putting them in enclosed space together in this situation.

We identified some people were at greater risk of developing skin cancer due to a family history. However, relatives and stakeholders had identified that people were not always being supported to apply sun cream during prolonged hot weather. Once identified, appropriate action was taken to prevent this happening again.

The provider did not detect or control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

People did not live in environments that were safe, and there were frequent incidents of physical assault between certain services users which the provider failed to appropriately learn from. This placed people in danger and fear. Relatives fed back that people had not been supported to live in environments that were clean, and hazards were not always appropriately identified. For example, one relative found a bathroom cabinet that had been damaged meaning sharp instruments like razors that could be used to cause harm. The provider had failed to identify this.

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

People were not supported by staff who had the skills to support them safely. There were significant gaps in staff training and knowledge which exposed people to a greater risk of harm. The provider had recently themselves identified that staff had a very poor knowledge of how to administer medications safely and had to remove all the staff at one person’s home from this task due to their concerns. Although staff competency had been reviewed, medications continued to be given contrary to clinical advice. Despite this, staff providing care to other people had not had their medication competency assessed since 2024, which meant there was a high risk of unsafe practice and errors happening. One person should have had rescue medication administered during seizures, but a large proportion of staff had not completed training in this since 2023. The provider had not recognised the importance of regular refresher training in emergency seizure medication which put people at risk of a prolonged seizure. The provider had not assessed the competency of their own staff to give this medication safely.

All people being supported had therapeutic models such as two person touch to redirect them and promote their safety during periods of distressed behaviour. These models of care were crucial to support the safety of other people and staff. Staff were not able to explain how to use them. One staff member told us “I don’t know how to do this, but other staff are around and could do it”. This was unsafe as it could not be guaranteed that this member of staff would not need to use these techniques as they worked in a house where there was frequent physical aggression. Other staff could not explain how they would ensure their own safety or use the technique if they themselves were in physical danger.

Most staff had not completed in person first aid training, meaning we were not assured they could respond if a person were to injure themselves. However staff did have training in basic life support.A large proportion of staff training around food safety had expired and we saw and heard examples of very poor food hygiene practices such as food being left uncovered for multiple days.

We could not be assured that staff had been safely recruited. We saw that 4 most recently employed staff had no evidence of interview records. The provider had already identified this risk and implemented a plan to regularly competency assess staff, however as detailed above this was not happening.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Although people lived in environments which were generally clean during our visits, stakeholders and relatives had previously identified concerns about how people were supported to maintain the cleanliness of their homes. This included concerns about unclean bathrooms, people’s bedding or clothing being visibly dirty and not changed, and poor food hygiene practices. One relative told us “The house was filthy before. It took so much time to support staff to clean it properly, and only just getting there now”. We found that some of these issues continued to be of concern. We saw an incident where a person was given mouldy food by staff. Although the person had stated they wanted to eat this item despite staff trying to dissuade them, it showed poor systems for monitoring the safety of food that this item had been able to become mouldy.

Additionally, several people were at risk of neglecting their personal care and we saw that they were visibly unkempt. Although there were strategies in place to encourage people to accept personal care, stakeholders and relatives had raised concern about how these were being followed in practice. People’s daily records of care did not show clear evidence when people declined personal care, staff would continue to offer support to maintain their dignity and reduce incidents of infection. For example, one person received personal care infrequently and their care notes showed no evidence that staff had encouraged or persevered to support them with personal care.

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

People were not consistently receiving medication in line with their assessed health needs. Where people had “as and when” medication prescribed for a specific need, staff were not proactively offering these in line with guidance which placed people at risk of pain or discomfort. Some people were not able to communicate the need for pain relief and relied on staff to identify and administer medication to them when they needed it. For example we identified where people had self-injurious behaviour or became distressed, in the majority of cases they were not offered painkillers or medications prescribed to reduce their distress. For example one person was described as banging their head against hard surfaces for up to 5 minutes at time to the point of injury but were not offered painkillers. This was despite people not being able to verbally request these themself and there was a risk of them being in pain or anxious without this being recognised. This in turn exposed them and others to a greater risk of harm, including repeated instances of physical abuse between people. A stakeholder involved in people’s care had stated “I am quite surprised how little paracetamol has been used given that this person frequently hurts themselves”. A relative we spoke to stated “I don’t think this has been handled well. It has never occurred to the provider that my relative could be putting themselves at risk because they are already in pain, because they haven’t been given painkillers”.

We saw other medication that should be given “when needed” was given on a daily basis in some cases contrary to guidance. We saw that one person had been prescribed melatonin for sleep, which had been reduced from daily to as needed medication in July 2025. However staff had continued to administer it daily for a further 10 months until this practice was identified as being inappropriate. This meant this person was being given medication which could make them drowsy or sleepy without purpose. Although this was amended, some members of staff we spoke to thought it had been stopped completely meaning we couldn’t be assured it would be administered as per the prescribed guidance

We saw another person who had been prescribed “as needed” painkillers had been given these 3 times a day for every day in June. Staff had not recorded why these were being given or if they were effective, which reflected a failure to monitor this appropriately. Once identified during the inspection, appropriate clinical advice was sought.