Archived: Sapphire Support Services Limited

On this page

• 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

The provider’s governance and quality assurance systems were not effective and had not ensured the delivery of good quality care and support to people. The provider has a poor history of non-compliance and a history of failing to respond adequately to serious concerns raised by the commission over a number of inspections. At this assessment we found a repeated breach of the legal regulations in relation to good governance. Shortly before our assessment a new manager had been appointed and was starting to address some concerns at the service. Whilst this provided some initial assurance, the improvements were only starting to be actioned and therefore were not yet embedded.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff spoke of concerns about the lack of leadership and guidance from the previous management team. However, staff told us things were improving, and felt supported by the new manager. Staff told us they now felt able to speak out if they needed to. Staff told us about some ways in which they supported people with their diverse needs.

The provider did not have effective systems that assessed and monitored the day-to-day culture of the service. Risk management was not robust and care planning was not person-centred, inclusive or collaborative. Staff supervision had been infrequent; these are important for promoting communication and building on a positive culture. The manager had started the process of addressing some of the above concerns but significant improvements were still needed.

Staff provided positive feedback about the new manager. However, the positive changes they referred to were recent, and not yet embedded in the service. Although improvements were being made, significant work was still required to ensure the regulations were met and people were safe. For example, care plans, risk assessment and learning from incidents required significant improvement. Staff had not been provided with all the training and support they needed to carry out their role effectively.

The lack of effective oversight of people’s needs and risk and the lack of consistent monitoring of incidents and accidents meant the provider lacked a clear understanding of current issues affecting the quality of people’s care. The failure to provide staff with regular supervision had hindered the provider’s insight into the culture within the service.

Staff commented negatively on the culture within the service which, until the recent arrival of the new manager, had meant concerns had not been acted on. They told us they could now speak to the manager when they needed to, and things were improving.

The provider had failed to foster a positive culture at the service. Issues and concerns had not been investigated thoroughly or sensitively or acted on. Any learning from concerns raised had not been shared with the staff team. The provider had not developed any formal systems and processes to gather feedback from people, professionals, relatives and staff. However, the manager had started to introduce these and provided us with some feedback from recent staff surveys, which were positive about the recent management changes.

Staff commented negatively on the culture within the service and they had not been empowered to share their views and suggestions about the service. However, staff told us they could now speak to the manager when they needed to, and things were improving. A staff member told us they now felt valued as a staff member and equality issues had been addressed, and they all worked as a team.

The provider had failed to implement systems to continually review and improve the culture of the service and to support staff to be the best they could be, in the workplace. We were concerned about how equality issues were addressed with the staff team, as recorded in staff meeting minutes. The manager assured us the issues raised, had been addressed and recent staff surveys completed confirmed this. The manager confirmed policies and procedures were in place and implemented, to support the diverse staff team.

Some staff did not have a clear understanding of people’s safety risks, and some health conditions. It was not always clear what action had been taken to differentiate between where a person had capacity to make decisions about areas of their life and where a mental capacity assessment was required. For example, in relation to support with medicine administration and support with managing finances. It was not always clear when talking to some staff, how they supported people when they refused care.

The provider had not developed effective governance systems and processes. This meant people were not always safe or provided with good quality care and support. The provider’s own governance systems had failed to identify shortfalls in quality and risks we identified during our assessment, or, if identified, had not effectively acted upon these. Audits had failed to identify care records were not always accurate, up to date, regularly reviewed or kept secure. Notifications were not always submitted to CQC as legally required. The provider had not implemented an effective system for monitoring and learning from incidents. The provider failed to implement relevant or mandatory quality frameworks, best practice or equivalents to improve equity in experience and outcomes for people using services.

People told us they were supported by staff to access healthcare services as needed. However, people’s care records were not always up to date with current information about how their health needs and how these were being met.

Staff were not always clear about the involvement of other healthcare professionals in people’s care including support from the district nursing team. Staff and management told us they were now working to improve relationships with stakeholders and health and social care professionals.

The local authority told us recent reviews of people’s care had taken place and improvements were needed. They found a lack of information about risks to people and care plans were not personalised.

The provider’s systems had not enabled them to ensure clear records were maintained in relation to people’s health appointments, the outcomes of these, any associated actions required and referrals. The incomplete and inaccurate information in some people’s care records did not support effective sharing of information and collaboration with relevant external stakeholders. The manager told us that improvements were being made to the standard of record-keeping and there was evidence of some improvements at the time of our assessment.

Staff told us learning had not been shared with them when things went wrong. However, with the change in management, they were now more involved with people’s care. They were also starting to complete the training needed, so they could be effective in their role when supporting people.

The provider’s systems and processes had not enabled them to effectively or consistently assess, monitor and address the safety and quality of people’s care and make required improvements in the service. They had not ensured learning happened when things went wrong, and shortfalls in quality we identified at our previous inspections had not been effectively addressed. There was no system in place for the effective oversight, monitoring or learning from incidents and accidents. There was no learning culture for staff and debrief sessions following an incident had not taken place, to learn from these events and improve people’s care. There had not been a focus and importance placed on ensuring staff had the skills to do their jobs well. Staff training needs had not been consistently assessed or addressed in a planned way.