Sublime Care

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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

During our assessment of this key question, we found concerns around the management of risks, which was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Despite generally good practices we identified skin integrity assessments did not consider all known risks. We identified errors in the medicine records and the provider did not always carry out follow-up actions when they identified fire safety risks. Most people told us they received care visits on time from regular staff. However, the electronic call monitoring (ECM) data we reviewed showed there were issues with the scheduling and logging of calls which meant there was a risk people would not get their care visits as planned. The provider’s recruitment processes was not always followed, we found some staff did not have a full employment history. We raised this with the provider and they resolved this shortfall immediately. You can find more details of our concerns in the evidence category findings below.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us staff understood their needs and provided them with the support they needed to keep them safe from harm. One relative told us, “Staff are vigilant about her skin and saw that her continence pads were too tight so arranged for bigger ones.” People were also assured staff used moving and handling equipment safely. One relative told us, “They’re always careful even though they must have done it hundreds of times together.”

In general, staff were positive about the processes in place to manage people’s safety. One member of staff told us, “I don’t have any concerns about safety. The management are responsive if you raise any concerns” and “The managers always come to see if everything is OK. They check that we are OK and we are doing what we are supposed to.”

There were a range of policies and process in place to manage risks to people’s health and wellbeing. However, we found these were not always effective and we found issues with person-centred risk assessments, medicines and fire risk. The risks associated with flammable creams was not always recorded accurately. For example, one person was using 2 different types of flammable creams but only one had been recognised as a potential fire hazard. There was no guidance in place to ensure the risks were being mitigated. We raised this with the provider and they have provided a fire risk information poster to alert staff of the risks, however, further improvements were needed to ensure staff understand how to mitigate the risks associated with the use of these creams.

People were protected from the risk of abuse. People and their relatives told us they felt safe using the service and staff were quick to identify areas of concern and take the right action. We received comments such as, “If we have any issues, we get a quick and positive response” and “They are so attentive and are quick to pick up on any changes and let us know.”

Staff received relevant training and showed a good understanding of whistleblowing and safeguarding procedures. They knew who to inform if they had any concerns about abuse and how to escalate their concerns if they were not satisfied their concerns were being taken seriously. A staff member told us, “For example one client had a bruise on her face. I reported it to the manager and she went to see the client to investigate.”

The provider made sure there were systems and processes in place to make sure people were protected from abuse and neglect. People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. The service worked well with other agencies to do so. The registered manager carried out investigations into allegations of abuse or neglect and provided feedback to relevant agencies. The registered manager understood their responsibility under the duty of candour and took responsibility when things went wrong.

People and their relatives had been consulted and treated as partners in the management of risks. Positive comments from people included, “I have been involved in [family member’s] care planning from the start and [family member’s] care plan evolves with the changes faced” and “Together we’ve worked out ways around problems and have never had even a close call!” Where issues had arose people felt the provider was quick to respond and resolve things. One person told us, “We had a few teething problems but the manager was always quick to respond to any issues and find sensible suggestions.”

Despite, generally positive feedback from staff we were not assured the provider understood their responsibility to assess and mitigate all risks. For example, we raised our concerns about the skin integrity assessments and the provider told us they were satisfied they had all taken all the necessary actions. They also told us they were not responsible for putting in place a diabetes risk assessment for someone with diabetes. Staff told us people and their families were involved in discussions about risks to their health and safety. They told us risk assessments contained accurate and up to date information to help them understand how to keep people safe. A staff member told us, “People and their relatives take part in the assessment. We also let them know if anything changes or things deteriorate. If things do change managers update the care plans accordingly.”

The quality of risk assessments and guidelines for staff were not consistent. The process for assessing the risk of skin breakdown was not in line with best practice. The skin integrity assessments did not quantify the level of risk and in some cases did not consider all known risk factors. We raised our concerns about the skin integrity assessments and the provider sent us additional assessments which had been completed more recently using a recognised skin integrity assessment tool which was designed to consider all risk factors and quantify the level of risk of harm. Despite these being a general improvement, we found further improvements were required as some of the more recent assessments had not been completed correctly and had missed some risk factors that could affect the level of risk of skin breakdown. Not all risks had been thoroughly assessed. One person was living with diabetes which meant they were at risk of having low blood sugar levels. Despite this the provider had not carried out a person-centred risk assessment for this condition and there was no guidance in place for staff about what to do if the person was experiencing low blood sugar. We asked the provider to ensure staff had the necessary information about all risks to people’s health and wellbeing and they have now put in place a diabetes risk assessment. Further improvements were needed to ensure the risk assessment contained all the necessary information such as signs and symptoms that might indicate someone was experiencing low blood sugar. The risks associated with moving and handling tasks were assessed and guidelines put in place. Some moving and handling assessments contained a good level of detail to support staff, whereas others lacked essential information about factors that might impact people’s moving and handling. People were consulted about their safety needs during the initial assessments and reviews.

People were satisfied risks associated with their living environment were considered and staff had the skills and knowledge to use the equipment such as hoists safely and effectively. We received comments such as, “I think they’d see risks all round, together we’ve worked out ways around problems” and “[Family member] has to be hoisted. They staff are always careful even though they must have done it hundreds of times together.”

We raised our concerns about the fire risk assessments with the registered manager and we were not assured they understood their responsibility to share information about risks they had identified and refer to other agencies such as the London Fire Brigade when they identified potential fire safety issues. We have shared some additional guidance with the provider to help them improve their understanding of their responsibilities.

The provider assessed risks associated with people’s living environments including the risk associated with fire. However, there was no follow-up actions or referrals made when people had multiple fire risks. The risks associated with flammable creams was not always recorded accurately. For example, one person was using 2 different types of flammable creams but only one had been recognised as a potential fire hazard. There was no guidance in place to ensure the risks were being mitigated. We raised this with the provider and they have provided a fire risk information poster to alert staff of the risks, however, further improvements were needed to ensure staff understand how to mitigate the risks associated with the use of these creams. We have shared some guidance with the provider about making referrals to relevant agencies such as London Fire Brigade when they identify fire risks. There were processes in place to ensure all moving and handling equipment was safe to use. Information such as maintenance history of equipment was in place.

Most people told us they received their care visits as planned. Positive comments from people included, “They come on time, I like an early start in the mornings. The carers text me to let me know they are on their way. They stay the full times too” and “Sometimes they stay longer if they haven’t done all they need to do.” However, this was not everyone’s experience and some people told us, “They have never actually missed but have been late sometimes” and “There are a few issues over times of visits, or sometimes a bit late.” Most people told us they received care from regular staff who had the skills and knowledge to care for them safely. Positive comments included, “They are all very dementia aware and keep that in mind when working.” and “The staff form a team and we know every one of them.” However, some people told us the care was not always from consistent staff. Comments included, “One thing that causes grief is when they send two strangers with no explanation given” and “The weekend carers are not so good, they don’t know [family member] so well.”

Staff told us they were happy with the induction, training and ongoing support they received to fulfil their role. We received comments such as, “The induction was really thorough” and “Recently I started working with someone with motor neurone disease. They provided training which included training around the use of the ventilator and suction device.” Despite the issues we found with scheduling of calls, staff told us their rota was well planned and enabled them to get to people on time. One member of staff told us. “The rota is good. I have enough time to get to each client. I have regular clients which helps you build a rapport.”

The provider had not obtained a full employment history for all new staff. We raised this with the registered manager and they have taken the necessary action to ensure each member of staff has a full employment history. The provider checked candidates' right to work in the UK, obtained references from previous employers and carried out Disclosure and Barring Service (DBS) checks. The DBS provides information on people's background, including convictions, to help employers make safer recruitment decisions. The provider ensured staff had the skills and knowledge to carry out their role effectively. Staff received an induction which included completion of the care certificate. Staff received supervision and an annual appraisal; however the frequency of supervision was not in line with NICE guidelines which suggests the recommended frequency of supervision is every three months. Not all staff had received training in delivering care to autistic people and people with a learning disability. There was no stroke training despite several people having a history of stroke. We raised this with the provider and they have now provided staff with stroke training. The provider used an electronic care monitoring (ECM) system to record staff attendance times to ensure people received their care visits as planned. We found issues with the scheduling and logging of care visits which meant the provider could not be assured all care visits went ahead as planned. At the time of the inspection the provider did not have a robust way of monitoring and auditing the ECM system. Although they had identified some issues they had not identified all the issues we found. We raised our concerns with the provider and they have made some immediate improvements following feedback. However, further improvements were needed which the provider acknowledged.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People who were being supported with their medicines were satisfied this was being managed safely. Positive comments included, “Mum is getting less ill under the care of Sublime, she is getting regular medication which I think was a problem with the previous care provider” and “The carers will let me know if she is running out of supplies or of medication.”

We discussed our concerns with the medicines with the registered manager. They advised us that they regularly audited medicines to identify issues or concerns. Despite this they had not identified all the issues we found and they have not provided assurance they will make all the necessary improvements we identified.

We were not assured the provider was following best practice guidance for supporting people to manage their medicines. The support required was not clear and/or person-centred. Several people’s care plan stated they needed level 3 support without any additional information about what this meant. The provider’s policy stated ‘level 3’ medicines support meant the use of specialised techniques but none of the records we reviewed contained any information about specialised techniques. Medicine care plans were also not always updated when things changed. One person’s medicine administration record (MAR) stated one medicine was to be administered 3 times daily, however, the MAR showed staff were only administering this twice a day. We raised this with the provider who told us the person’s family member had taken responsibility for administering this particular dose temporarily. The care plan had not been updated to reflect this change. The guidance in place for PRN (when required) medicines was not always sufficient. One person was prescribed a topical cream and the directions in place for staff were to apply this 3 or 4 times a day, however, the MAR showed staff were applying this medicine only once a day. The directions also did not indicate where to apply the topical medicine. We raised this with the provider and they told us the pharmacy has subsequently confirmed the medicine is (PRN) and the person routinely needs this in the morning. This information was not in the care plan and the provider has not told us what they will do to improve the PRN directions for medicines generally. Another person was prescribed a medicine that needed to be given every 12 hours. However, the times of administration were not recorded on the MAR.