Sevacare - Hall Green

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• 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

Systems to assess, monitor and mitigate risks to people, including risks associated with people's long-term health conditions, were not robust or effective. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Staff did not report incidents in a consistent or timely manner, which meant opportunities to learn from these and reduce risks to people were lost. Where incidents and safeguarding concerns had been reported, lessons had not always been learned or improvements embedded into practice. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People's rights under the Mental Capacity Act 2005 were not always fully supported or understood by staff. Staff had not always received appropriate training relevant to their role. Recruitment procedures were robust and people were supported by adequate numbers of staff. People were supported to take their medicines safely. People were protected from the risk of infections.

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.

People and their relatives told us they knew how to speak up if they had a concern about their safety and felt these issues were addressed by the provider. One relative said, “We know what to do if we have a concern. It is the same [staff] we speak to who come to reviews.”

A lack of consistent training and guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not demonstrated. Staff did not consistently report incidents and accidents, which meant opportunities for learning and improvements to people’s care were sometimes lost or delayed. The registered manager completed detailed investigations into safety incidents or complaints brought to their attention. However, lessons learned were not always shared with staff and embedded into practice to help mitigate future risks.

Staff told us they had not received training to help them manage risks associated with people’s health conditions. Some staff did not know how to respond to health emergencies and said they would call the office for advice. If relatives were not present to support them, the delay caused by calling for advice could place people at increased risk of harm in an emergency. Staff told us they would call the management team if they had any concerns or felt information needed to be added to people’s care plans. They said this would result in the changes they requested. One staff member said, “Yes, we do mention anything that has gone wrong. [The management team] do listen, they are very good.” The registered manager understood their duty of candour responsibilities.

Care plans for people receiving care after hospital discharge contained limited information. Some staff told us these care plans did not contain enough guidance and information to enable them to fully understand or meet people’s care needs. The management team told us the hospital provided this information and it was not always very detailed.

Processes did not ensure staff supporting people following hospital discharge had clear guidance on, and awareness of, their individual needs and risks to keep people safe. We found no evidence this had caused harm to anyone. However, delays in producing robust care plans placed people at increased risk of inappropriate care and unmet needs. Reviews of people’s needs and care plans were not robust or consistent.

Systems and processes to protect people from abuse and neglect were not effective enough. Staff did not consistently report incidents and accidents, which increased the risk of immediate action not being taken in response to safeguarding concerns. For example, one person’s care records showed a significant deterioration in their skin condition. There was no record that this had been reported by staff or action taken in a timely way, which could have prevented this deterioration. People’s rights under the Mental Capacity Act 2005 were not fully supported or always understood by staff. The information recorded on some people's consent to receive care documents was unclear. There was no evidence of best interests decision-making for one person who was subject to restrictions. Where mental capacity assessments and best interest decisions had been completed, these did not clearly demonstrate how conclusions had been drawn.

People and their relatives understood how to raise any abuse concerns they may have. Most people and relatives we spoke with told us they felt safe being supported by staff and did not have concerns about their safety. One person who was asked if they had ever had concerns about their safety, told us, “No never, I have been very lucky.” However, one person’s relative expressed concerns regarding the effectiveness of staff communication and the impact this had on the person’s safety.

Staff told us they had received safeguarding training and could describe circumstances which would lead to them following the services safeguarding policy and procedure. However evidence suggested the system for reporting incidents and accidents, which could be of a a safeguarding nature, was not always followed by staff. Leaders did investigate and share safeguarding concerns with the local authority’s safeguarding team when they were identified. People's rights under the Mental Capacity Act 2005 were not fully upheld. There was a lack of consensus amongst staff and management regarding people's mental capacity. The management team told us no one currently in receipt of care and support had difficulties making day-to day-decisions for themselves. However, most of the staff we spoke with told us they had to support people with decisions of this nature. Not all staff understood people's rights under the Mental Capacity Act 2005. For example, one staff member told us they had never had training on the Act, adding they had ‘never needed it'.

Risks to people had not always been assessed with them or clear plans developed, with accompanying guidance for staff, for managing these. This included the failure to consistently assess and manage risks associated with people’s specific health conditions, such as diabetes or epilepsy. Some people's care plans lacked clear guidance for staff about their role in monitoring and helping people to manage health conditions. For example, some people's care plans did not mention potentially serious ongoing health conditions and associated risks. Guidance for staff in care plans about people’s epilepsy was limited and not person-centred. The management team did not have effective oversight of current risks to people due to ineffective incident reporting processes. They told us they would review everyone’s care plans to ensure individuals’ risks had been assessed and staff provided with clear guidance on managing these.

People and relatives gave mixed views about how risks were assessed and managed. One relative told us they were concerned that a risk regarding communication with their relative had not been addressed. We raised this with the registered manager, who said they were endeavouring to recruit staff who could mitigate this risk. However, an interim plan to manage the risk was not in place. This meant the person remained at increased risk of harm. One person receiving care and a relative told us they had not always been supported by staff who understood their care and support needs. We told the registered manager about this. They reminded staff to ensure they checked people’s care plans before supporting them if they were unfamiliar with their care needs. Other people and their relatives told us they felt staff knew their care needs well and knew how to support them to manage risks.

Staff we spoke with were not always aware of risks to people and their role in monitoring and managing these. They did not always know how to manage risks associated with people's health needs, including the action to take in the event of an epileptic seizure. They told us they had not received training in epilepsy. One staff member we spoke with was unaware they were supporting a person who had epilepsy. The management team told us staff had received training in people’s health conditions, such as epilepsy and diabetes, but no evidence was provided of this. Some staff told us the care plans for people discharged from hospital sometimes lacked enough detail to know what people’s care needs were. They told us they had to rely on people and their relatives to update this information and ensure guidance was appropriate. One staff member said “[The hospital discharge care plans] are basic, but they improve over time.”

The provider’s electronic call monitoring system was not always used correctly by staff or audited effectively. We looked at care call records for January 2024 and saw some staff were logged into 2 calls at the same time. We spoke to the registered manager about this. They told us the matter was being looked into, but it had not been identified by the management team’s regular audits of the electronic call monitoring system.

The provider had not always taken all reasonable steps to control risks in the care environment. We discussed with the management team a serious safety event that had occurred in one person’s home. They were unable to demonstrate any actions taken to reduce the risk of reoccurrence. The provider used an electronic call logging and monitoring system to support staff to deliver safe and effective care. However, some staff told us they did not record travel time between calls on this system and left people’s care calls 5 minutes’ early to reach the next call on time. We spoke to the registered manager about this. They advised it was not the correct procedure to use call time to travel to another call. They told us staff were allowed to leave the care call early if all the required tasks were done. This was permitted as long as the person receiving support stated that they did not need the staff member to provide any further support. The registered manager said they would speak to staff and remind them about the correct procedure.

People and their relatives told us they were mainly supported by the same group of familiar staff. They felt the provider employed sufficient staff and said if a staff member was unavailable they were usually replaced with another. Although people and their relatives gave mixed views about the punctuality of the service, they did not express significant concerns about the impact of late calls. Most people and relatives said staff were suitably experienced for the role.

Staff felt the provider employed enough staff to deliver a reliable service, and confirmed they were given travel time between people’s care calls. However, staff we spoke with told us they had not always received appropriate training relevant to their role, or could not recall this training. For example, one staff member said they had not had training on people’s rights under the Mental Capacity Act 2005. Some staff told us they had not had training on their role in supporting people with long-term health conditions. Some staff told us they mainly did online training, and they would prefer more of a balance of face-to-face and online training. One staff member said, “You can’t ask questions with e-learning.” We shared this feedback with the management team who said they were planning to introduce more face-to-face training in the future.

The provider had not always ensured staff were kept up to date with good practice and had completed all the training they needed. The provider’s staff training matrix indicated staff received regular training in a number of areas, but this did not include training on people’s specific health conditions. Our analysis of the provider’s electronic call monitoring system showed sufficient numbers of staff were available to support people. New staff went through an induction which included training and opportunities to shadow experienced staff to help them learn the skills they needed. Records showed staff received regular supervision. The provider followed robust recruitment procedures to ensure staff were suitable to support people in their own homes.

Staff told us they received training in infection prevention control. They also said they had access to plentiful supplies of the right PPE. The provider and staff were aware of current relevant national guidance. One staff member told us, “We always have enough PPE. We collect what we need, we have everything there.” Staff described the ways in which they disposed of used PPE in line with people’s individual preferences.

The service used effective infection, prevention, and control measures to keep people safe. Staff had access to policies and procedures to ensure they kept up to date with any changes in guidance. Infection prevention was included in staff inductions and then refresher training was provided periodically to ensure staff remained updated with current guidance and practices. Checks on staff adherence to the correct procedures were included in spot checks of care provided to people.

One person and 1 person’s relative told us staff did not always wear personal protective equipment (PPE). We told the registered manager about this, who sent out a message to all staff reminding them to wear the required PPE at all times. All the other people and relatives we spoke with were happy with the staff team’s approach to hygiene and cleanliness. They told us staff wore PPE in line with their specific needs. They told us they felt supported to remain safe from the risk of infections.

Most of the staff we spoke with told us they received training to support people to take their medicines safely. One staff member said they did not recall having training but said they did have spot checks to ensure they were supporting people to take medicines safely. The management team told us they ensured all staff received medicines training at induction as well as refresher training.

People receiving care from the service and their relatives told us they were happy with the support they received to take their medicines safely.

People were supported to receive their medicines safely. The provider had policies and procedures for safely managing medicines and staff followed these. Staff kept accurate records showing when medicines had been given. People’s care plans contained information about how they wanted to be supported to take their medicines. Medicines audits were completed to help ensure medicines were managed safely. Spot checks of staff during care calls included checks to ensure they were following correct procedures.