Archived: Sapphire Support Services Limited

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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

We identified 3 breaches of the legal regulations in relation to safe care and treatment, safeguarding and staffing. Staff did not always assess risks to people's health and safety or mitigate them where identified. Risk assessments were sometimes incomplete and did not always include risks we identified during our assessment. Staff did not always have the knowledge to recognise how to support people to live full lives. There was no system in place for the effective oversight of incident and accident recording, reporting and monitoring. Medicines were not always safely managed. Staff were safely recruited and people were supported by adequate numbers of staff.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People provided some mixed feedback about the care they received and told us that, until recently, they had not felt their views and concerns were listened to by the management team. They told us since the new manager was appointed, things were improving. One person told us, “Things never got done before, but the new manager is brilliant. They listen and they get things done.”

Staff told us about a poor culture at the service under the previous management. Staff told us when concerns were raised previously, they did not feel listened to. They told us they now felt listened to and confident any concerns would be acted on. A staff member told us, “We raised concerns previously and nothing was done; we were not listened to. The new manager is very good, and I feel supported now.”

Health and social care professionals told us people’s care plans and risk assessments lacked detail, were not personalised, had not been kept updates and there was missing information in people's care records.

Risks to people were not always assessed or action taken to mitigate these. Care plans and risk assessments were not always in place for known risks, kept up to date or reviewed following an incident or changes in risk. This included the failure to assess and manage risks associated with people’s mental health needs, physical health and behaviours. This meant opportunities for learning and improvements to people’s care did not always take place. Incidents and accidents involving people were not consistently reported by staff, monitored, investigated or learned from to reduce the risk of reoccurrence and improve care. Oversight of accidents and incidents was ineffective, and there was no analysis of associated patterns and trends. Staff were not informed of any associated learning from accidents and incidents to keep people safe. The provider failed to implement their own policy on incident and accident reporting effectively. The manager had only been in post for 4 weeks. They had started to improve systems and processes in relation to accident and incident monitoring and risk management. This included reviewing and updating people’s care plans and risk assessments.

One person told us they had access to health care professionals and could make an appointment with the GP when they needed to. However, we found people’s care records were not being updated to reflect their current health needs and changes in people’s health were not always promptly addressed.

Staff told us they had an opportunity to read people’s care plans and they were provided with information about people’s needs and health care conditions. However, we found some staff were not aware of people’s physical or mental health conditions, the role of external healthcare professionals involved, or their own role in supporting people to manage these conditions. The manager told us good working relationships had not previously been developed between the service and other partners in people’s care, including other healthcare professionals. They told us they were now working on improving these relationships.

Health and social care professionals told us people’s care plans and risk assessments lacked detail and records were incomplete.

The provider had processes in place for the continuity of care between services, and a process for an initial needs assessment, at the start of the service being provided. However, many of these records could not be made available to us and we were unable to confirm that these processes had been implemented effectively. Some people were experiencing significant changes in their physical and mental health needs, which had not been consistently or accurately recorded. Prompt referrals to relevant health and social care professionals had not always been made in response to changes in people’s needs. This placed people at an increased risk of harm. Records that we could review did not demonstrate that care and support was consistently planned and organised with people and professionals involved in their care.

People knew how to raise concerns and told us they felt safe. One person said, “I am happy with the staff.” Another person told us, “I know how to get support or upset, I would call staff for support.”

Not all staff had completed safeguarding training. However, staff we spoke with knew how to report safeguarding concerns. A staff member told us, “I have no concerns about people’s safety, and would report any concerns to the manager.” Some staff lacked understanding about people’s capacity to consent to care and treatment and how to protect people’s rights under the Mental Capacity Act 2005 (MCA). This included the implications of the MCA for medicines management and the management of people’s finances. The management team were unable to explain why safeguarding concerns had no been consistently notified to the relevant external agencies, including CQC.

We observed people receiving care and support from staff during our assessment, with no safeguarding concerns observed.

The provider had systems and processes to protect people from abuse and neglect; however, these processes were not robust and had not been followed consistently. Some safeguarding concerns identified during the assessment from reviewing records, had not been raised with the local authority. The manager took action to notify the local authority of these concerns, once we brought this to their attention. However, this meant the provider had failed to act promptly and appropriately when people had been at risk of harm. Following incidents, care plans and risk assessments were not reviewed and updated to ensure the control measures and plans remained appropriate, and people were protected from harm. Some known risks to people were not considered, and planned for, which had the potential to place them at risk of harm as appropriate guidelines were not in place for staff to follow. Systems in place for supporting people with managing their finances were not robust. Some staff were handling people’s personal money and bank cards and purchasing items on people’s behalf, without appropriate safeguards or monitoring systems in place. The level of support a person needed with their finances had not been assessed, and systems were not in place to ensure people were protected from the risk of financial abuse. This included the failure to maintain appropriate financial records or retain receipts of transactions.

People gave us mixed views about how risks were assessed and managed. People told us more discussions with staff about their care and associated risks had taken place in recent weeks. One person told us, “Things have improved over the last 4 weeks or so, there is a new manager. Staff have spent time going through my care plan in the last few weeks with me and I have been able to contribute to this. My old care plan which was reviewed was out of date by years, as things which were on there were really out of date.”

We received mixed feedback from staff on the assessment and management of risks to people. Some staff knew the people they supported well and knew how to support them to stay safe. However, other staff had only a basic understanding of people’s care needs and were not fully aware of people’s diagnosis and health conditions. This meant there was increased risk staff may not have the appropriate knowledge or information to support people safely.

We observed hazards in the environment in which people were receiving care and support from staff. This included trip hazards in communal areas and faults with a fire door.

The provider's processes for identifying, managing and reviewing risks were not robust. Risks to people had not always been assessed with them or clear plans developed to mitigate these, with accompanying guidance for staff to follow. This included a lack of clear staff guidance on how to manage people’s pressure care and promote their skin integrity. One person’s risk of self-harm had not been assessed or managed, along with the risks associated with other people’s specific health conditions. People’s care plans and risk assessments contained incomplete or contradictory information. Failure to understand and manage risks to people placed people at an increased risk of harm. The manager told us they were working to improve the guidance and information in people’s risk assessments, as part of which they were seeking to clarify their understanding of people’s risks,and to locate associated documentation.

People told us staff carried out some safety checks and fire drills took place. One person told us staff were helping them to personalise their room and they had recently put some new shelves up for them. One person told us they were waiting on some mobility aids to be fitted to their bathroom.

We identified some potential trip hazards in the shared areas of the service, including the lounge and corridor. Although, once brought to their attention, the manager took prompt action to deal with these, they were unable to explain why not had not been identified and rectified previously, or why fire safety deficiencies brought to the provider’s attention had not been more promptly addressed.

We observed hazards within the care environment, which the provider had not addressed. This included concerns around potential trip hazards in communal areas and the integrity of a fire door. The kitchen had been refurbished since our last inspection. We saw a domestic staff member carrying out cleaning of communal areas.

The provider’s processes for managing the safety of the environment were not always robust. There was no environmental risk assessment in place to consider risks within the care environment. This was completed by the provider during our onsite assessment. Fire safety risks had been assessed by a specialist. However, there was an outstanding fire action in relation to a storage area that needed attention to make it safe, and this had not been addressed since April 2024.

People told us they had not always felt listened to by, or had enough time and support from, staff until recently. However, they said things were starting to improve and staff were spending more time with them and talking to them. One person told us, “I didn’t have a real schedule of care and staff would often just pop their heads in the door and ask if I was okay. Over the last few weeks things are improving, and staff are being more specific with the time they spend.”

The management team were unable to explain why staff training needs had not been consistently assessed, monitored or addressed, to ensure staff had the knowledge and skills to work safely and effectively. Staff told us since the change of manager they were now starting to receive the training needed to carry out their role. A staff member told us, “We have started to do training now I have started a few of the eLearning sessions. I have not completed them it’s sometimes hard to find the time. Its good because we can discuss the training with the manager.” A recently-appointed staff member told us, “I shadowed for 3 days with an experienced member of staff. I had the opportunity to meet people and become aware of their routines, and tasks (to be completed) during calls.”

Staff were available to support people, and we saw staff respond to people's request for assistance.

Our last assessment of this service found there was no staff training needs analysis, and people were not always confident in staff’s abilities to carry out their role. At this assessment, people were still not being consistently supported by staff who had the training they needed to perform their roles. The provider’s training matrix indicated that, although some training had taken place, a number of staff still had not completed initial or refresher training on topics the provider had identified as required for their role, such as safeguarding, basic life support and fire safety awareness. The manager told us since coming into role they had identified the need for further staff training, and this was now taking place in a planned way. Records of staff supervision indicated this had been infrequent and inconsistent. However, the manager told us improvements were being made on the frequency of this support. Staff were safely recruited and received an induction. All staff were working towards the Care Certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme. The manager told us they had started to carry out practice competency assessments and, so far, this has included areas of medicine administration.

People told us staff helped them to keep their property clean. We saw cleaning was taking place of communal areas.

The manager acknowledged that most staff had not received training in infection prevention and control and was unable to offer a rationale for this gap in training provision. Staff told us they had access to personal protective equipment such as gloves when needed.

We saw staff undertaking cleaning tasks of communal areas and staff had access to cleaning materials and PPE.

There were no systems and processes in place for the oversight of standards of infection control (IPC). The manager told us they would be implementing these imminently, including IPC audits.

People did not always feel they had received the support they needed to manage their medicines as independently as possible, and the lack of self-administration assessments in the care records we looked at confirmed this. One person told us they wanted their medicines to be stored back in their own property, and not held centrally, to promote their independence. Where people needed support from staff to take their medicines, they told us they received this support.

Staff told us they had received training to support people to take their medicines safely. A staff member told us, “I have completed medicine training, and the new manager has also completed a competency assessment.” Some staff told us the arrangements for medicine management needed to be improved.

Not all people had a safe place in their property to store their medicines. The provider was storing medicines centrally in a medicine room.

The provider did not have robust processes in place for managing people’s medicines safely, that reflected people’s capacities and preferences. People’s medicines were stored centrally in the medicine room, and not in their own property. There was no assessment of the level of support people needed, if any, to manage their medicines safely, and no self-administration assessment or care plan detailing how staff will support the person’s independence in managing their own medicines. Effective oversight of the management of controlled medicines had not been maintained in line with the provider’s medicines policy. Controlled drugs were not safely stored, being kept alongside non-controlled drugs, and there was no process in place to monitor the current stock and administration of these medicines. The controlled medicines held on site had not been recorded within the control medicines record book. The unsafe management of controlled medicines increased the risk of medicine errors. When a person was not able to manage their prescribed medicines safely there was no evidence of any associated mental capacity assessment or best-interests meetings taking place. Risks associated with the handling and administration of people’s medicines had not been assessed, including time-specific medicines and medicines to be taken before food.