Pleasant Valley Care Shropshire Branch

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 newly registered 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.

The service was in breach of legal regulation in relation to safe staffing.

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. Lessons were not always learnt to continually identify and embed good practice. Staff listened to concerns about safety and investigated and reported safety events.

Staff knew how to raise safety concerns, and they told us they felt able to do so. The registered manager acted upon safety concerns raised, demonstrating a commitment to responding to immediate risks and improving day-to-day safety. However, this was not consistently underpinned by an open and transparent learning culture at organisational level. During the assessment, the provider did not provide accurate and complete information regarding the staff employed and the people using the service. This lack of candour limited the ability to robustly review and learn from concerns and did not reflect the expectations of a positive safety culture, where honesty, transparency, and accountability are fundamental to continuous learning and improvement.

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.

Systems were not always safe because the provider had not ensured staff received appropriate training to carry out their roles effectively, which increased the risk to people using the service.

Daily logs were thorough and systems were in place to ensure important information regarding changes to people’s care needs or concerns were shared between carers. However, where a carer did not yet have access to the call monitoring system, electronic care systems were not always updated in real time which may have led to gaps in information sharing.

The provider was transparent with people and relatives regarding staff contingency arrangements at the commencement of care packages and was flexible where possible. However, there were limited systems in place for unplanned events due to the limited number of staff employed. This meant staffing arrangements were not always robust to ensure care could be covered effectively in emergency circumstances.

The provider was not assured staff had adequate safeguarding knowledge and that concerns would be shared quickly and appropriately. Staff did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Whilst the provider dealt with any known concerns, 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 due to a failure to ensure staff competency.

The provider had failed to ensure staff had completed safeguarding training which meant they could not be assured staff would report allegations of abuse. Some staff told us they had completed training and all staff reported they would escalate safeguarding concerns. However, staff knowledge regarding safeguarding processes was mixed.

Whilst we did find some evidence accidents and incidents were appropriately managed, they were not formally recorded and there was no oversight of these to identify any trends or patterns.

Despite the lack of training, people and relatives told us people were safe and they were confident the provider would deal with any safeguarding concerns appropriately. One relative told us, “The registered manager would definitely raise any safeguarding concerns if there were any”.

Where safeguarding concerns had been identified, these were shared with the local authority in a timely manner, and statutory notifications were submitted to CQC where there had been allegations of abuse.

The provider was proactive in identifying what being safe meant to people, where they had identified safeguarding concerns. Where safeguarding concerns had been raised for one person, the provider met with them regularly after to discuss their concerns and ensure they were doing all they could to maintain the person’s safety.

The provider worked well with people to understand and manage risks. However, staff were not always sufficiently trained which meant the provider could not be assured they were able to provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Whilst people had risk assessments in place to guide staff how to manage risk to them, the provider could not be assured staff were competent to manage these risks as not all staff had received appropriate and up to date training.

Where risks were identified in relation to one person’s nutrition, the person’s care plan clearly guided staff how to cut their food to reduce risk to them.

Daily records were detailed and showed staff supported people to make their own choices while managing risks appropriately, demonstrating respect for people’s wishes and preferences.

Risks were considered as part of reviews of people’s care and the provider took steps to reduce risk to people where needed. For example, where one person’s care was being reviewed, risks were discussed with them, and their relative and additional measures were put in place to reduce trip hazards in the home. The person’s care documentation was then updated to reflect the change to the risk assessment and ensure staff were aware of the changes.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The safety of people’s home environment was considered from the outset of their care package. The provider completed a “start of care checklist” following discussions with people and their relatives which focused on promoting a safe environment for them including ensuring good lighting at the entrance, clutter free access routes and non-slip flooring.

Daily records demonstrated staff consistently checked and managed environmental risks, including securing doors, ensuring emergency equipment was available to people when they went out, and checking kitchen equipment.

Staff recorded any concerns around the environment in their daily logs and action they had taken to address it. For example, where a person had broken a jar prior to the care call, staff cleared this up to ensure the person’s environment remained safe.

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.

Safe recruitment practices were not followed. Although Disclosure and Barring Service (DBS) checks had been completed for all staff, the provider had not obtained or retained other essential recruitment information. This included fully completed application forms, comprehensive employment histories, health declarations and evidence of induction. This meant the provider could not be assured staff were suitable for their roles.

The provider did not ensure staff received appropriate training to carry out their roles safely. Training records were incomplete, and several staff were not included on the training matrix. As a result, the provider could not demonstrate all staff had completed mandatory training. In addition, the training matrix had not been reviewed or updated since May 2025, indicating a lack of effective oversight.

There were insufficient assurances staffing levels and deployment were safe. Whilst the provider attempted to arrange cover when regular staff were unavailable, robust recruitment checks had not been completed for all staff providing this cover. This meant the provider could not be assured staff had the necessary skills, knowledge and competencies to meet people’s needs safely, particularly when supporting people on an ad hoc basis.

Staff did not receive regular supervision or annual appraisals. This meant there were no consistent opportunities to assess staff competence, identify learning needs or ensure safe practice was maintained.

Despite these concerns, people and their relatives provided positive feedback about the staff supporting them and felt their needs were met. Staff, including those providing cover, told us the registered manager arranged shadowing opportunities and shared information about people’s needs prior to them delivering care. However, these measures were not sufficient to mitigate the risks identified in relation to recruitment, training and oversight.

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.

People told us staff wore PPE in line with current guidance. Sufficient supplies of PPE were made available to staff, enabling them to minimise the risk of cross-contamination between visits.

The provider made clear within their “start of care checklist” what hand hygiene and infection control measures would be required within the person’s home. For example, access to an appropriate handwashing area and an appropriate bin to safely dispose of Personal Protective Equipment (PPE).

Staff were knowledgeable regarding how to reduce the risk of spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Whilst staff did involve people in planning, the provider did not always ensure staff had undertaken adequate medication training or check staff medicines competencies.

Daily records clearly recorded when people required support to take their medicines, including eye drops. However, not all staff had completed safe medicines administration training, which increased the risk to people using the service. The provider also failed to undertake adequate and objective medicine competency checks to assure themselves staff were able to administer medicines safely. Despite this, people and relatives told us medicines were administered as prescribed and they did not have any concerns regarding staff competence.

Medicine administration was recorded on the Medicine Administration Records (MARs) on the call monitoring system. Office staff monitored alerts regarding medicine administration and if there were any potential concerns, they addressed these and recorded comments on the person’s MAR. For example, where one person had a hospital visit which meant they were not at home to be administered their medicines, this was recorded on their MAR to explain why it wasn’t administered.

Protocols were in place for ‘when required’ medicines to guide staff when they should be administered and how to administer them safely.