Sowa

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During our assessment of this key question, we found improvements were needed in management oversight and governance in relation to medicines management, quality of risk assessments, care plans and mental capacity assessments. This same issue had been identified at our last inspection. The provider’s oversight and governance failed to ensure systems and processes identified the improvements needed in the quality and safety of care being provided. The registered manager did not have a good understanding of the remit of care provided under the regulated activity of personal care and that a registered provider cannot delegate to other agencies to have oversight of the care being provided. We found the systems in place were not ensuring accidents and incidents happening during delivery of care were known or analysed by the registered manager. Relatives told us they felt able to raise concerns and that these would be acted upon. Staff told us they enjoyed working at the service and felt well supported by the registered manager. There were processes in place to support staff in having the skills they required to complete their work safely, and to continuously be supported via supervisions.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us they wanted to provide a service that was safe to people and met their needs. They told us the management team had been through some changes recently and the registered manager would now be more involved in overseeing care and complete quality assurance.

During this assessment we found that although team meetings were taking place and staff told us these were supportive, we did not see evidence of how issues about delivery of care and values of the service were discussed. We received consistently positive feedback about the care being provided to people.

Staff told us they enjoyed working at the service and felt well supported by the registered manager. A staff member told us they found their manager very fair and approachable. Another staff member commented, "Yes they [management team] are very good and approachable."

There were processes in place to support staff in having the skills they required to complete their work safely, and to continuously be supported via supervisions.

Staff told us they could raise concerns and management would take action. Their comments included, "Yes when we have meetings, they [management team] ask us this [if we have issues] and we can always say. They are very open. They are good. They answer all your questions we can always call them."

There were policies and procedures in place to encourage people, relatives and staff to speak up and we found these were being followed. Relatives told us they were confident in raising any concerns to the manager and were confident these would be acted upon. A relative commented, "There have been times when I have contacted the office over some billing issues, and these have been sorted out immediately to my satisfaction."

Staff did not raise concerns about equality and diversity. They felt supported by management and happy in their roles.

Staff completed training in equality and diversity. The staff employed at the service and people using the service were from a range of backgrounds. Staff completed an Equal opportunities questionnaire as part of their induction. Staff felt supported by the managers and spoke positively about the provider.

Although the registered manager told us they completed regular audits and reviewed the care delivered by staff, during our inspection we found a lack of evidence of this happening in an effective way. For example, slips trips and falls audits completed for September 2024 did not highlight the fall one person had, and that an accident report had not been completed. Care planning audit completed in September 2024 did not identify any issues, and during this inspection we found several issues with care planning, risk assessments and MCA documentation.

Quality assurance systems were not effective. Audits completed were not detailed and had not identified the issues found at this inspection for example, with medicines management, quality of risk assessments, care plans and mental capacity assessments. This same issue had been identified at our last inspection. The registered manager did not have a good understanding of the remit of care provided under the regulated activity of personal care and that a registered provider cannot delegate to other agencies to have oversight of the care being provided. We discussed with the registered manager about the lack of oversight of care provided to people, in particular to care delivered in Sheffield. The lack of effective governance and oversight meant the provider and the registered manager were unable to promptly identify concerns that could put people at risk of harm or injury. We did not see evidence of the provider completing staff, service user or relative's surveys/questionnaires to ask for feedback from people in relation to the management of the regulated activity.

Relatives told us they worked in partnership with the provider. One relative said, "The company have really listened to us and work with us." Relatives said they were consulted and involved in people's plans of care. One relative told us how their relative was supported with wide ranging opportunities in the community which they wanted to be involved with.

The registered manager was able to tell us how they would make referrals to appropriate external agencies or professionals to meet the needs of people.

We did not receive any feedback from partners about this quality statement for this assessment.

People were referred to other services appropriately and professionals’ advice was included in people’s care plans.

Although the registered manager told us they analysed incidents and looked for patterns, in our review of records we found a lack of oversight in this area. Staff told us they were confident to raise any issues to the registered manager.

We found the systems in place were not ensuring accidents and incidents happening during delivery of care were known or analysed by the registered manager. We found examples of accidents recorded in care notes, but these were not listed in the registered manager's accidents log and the registered manager was not aware of these. For example, one service user had become agitated during a visit from staff, screaming and attacking staff however there was no incident report completed. This service user had been involved in two incidents which hadn’t been reported or analysed for trends or themes to prevent re occurrences.