Sevacare - Hall Green

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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

The provider’s governance and quality assurance systems were not sufficiently effective to ensure the delivery of good quality care and support. Audits and checks completed had not enabled them to identify and address a number of significant concerns we found during this assessment. These included shortfalls in the assessment and management of risks to people. Learning from investigations into concerns was not consistently identified or shared with staff to drive improvements in people’s care. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff and management were not always clear about their individual roles and responsibilities, including the need for staff to consistently report accidents and incidents. The provider did not always liaise effectively with partners for improvement. This included a lack of clear information and guidance for staff in people’s care plans following hospital discharge. Staff felt well-supported by management and felt confident about speaking up at work.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Processes ensured staff had a shared vision and values regarding the care and support delivered. People and their relatives had been provided with clear information on how to raise suggestions and concerns about the service. Management initiated surveys to seek people’s views about the service, enabling them to contribute to its development. However this process, in combination with reviews of people’s care plans, had not always ensured a fully inclusive and collaborative process of care plan development. The provider’s processes and training provision had not ensured a clear understanding and promotion of people’s rights under the Mental Capacity Act 2005. Risk assessment and care planning processes had not always resulted in care plans which reflected and acknowledged people’s diverse needs. For example, one person who was unable to communicate verbally did not have detailed guidance in their care plan about how staff would know if they were in pain or discomfort. This meant staff, who did not know the person well, may miss indications the person was communicating pain or distress.

Staff we spoke with understood the values and vision for the organisation. Staff and management understood the importance of listening to the views of people and their relatives on the service. Staff understood people’s human rights and told us about some ways in which they supported people with their diverse needs. The management team did not have a clear or well-developed understanding of people’s rights under the Mental Capacity Act and their associated responsibilities.

Staff told us the management team were accessible and approachable. They told us they felt supported and that if they needed to speak to a manager, they were easy to contact. One staff member said, “Managers are easy to get in touch with. Also, the out of hours, there is an on-call system 24/7.” The management team understood how to promote safe recruitment practices.

There was a whistle blowing policy in place. Staff were informed about this as part of their induction. Staff could access the policy electronically if needed.

Staff told us they knew about the service’s whistleblowing policy and knew how to raise concerns if they had any.

Staff felt the management team took into account their equality, diversity and inclusion and treated them fairly. They gave examples of information and guidance they had received from the provider to help support them with their particular circumstances. Many staff told us they were offered flexibility to enable them to gain what they felt was a good work life balance. Staff told us they attended regular staff meetings, which were productive and enabled them to openly raise issues and concerns.

Staff and management we spoke with told us they were clear about their individual roles and responsibilities as these related to delivering good-quality care. However, we found practices and the information they gave us did not always reflect this. For example, the management team were unable to provide us with accurate information about people’s mental capacity, which impacted their role in ensuring people’s rights under the Mental Capacity Act 2005 were fully supported. They also told us they maintained effective oversight of staff training needs but were unable to provide us with a comprehensive overview of staff training. The management were unable to explain the actions taken to mitigate some known risks to people. Management were aware of when to notify incidents to the relevant external agencies.

The provider’s governance systems were not effective enough and had not enabled them to monitor and manage risks to the safety and quality of people’s care. Audits completed by staff and management had failed to identify significant issues we found, including ineffective assessment and management of risk, inconsistent reporting of accidents and incidents and insufficient provision of training and guidance for staff in some key areas. In addition, the auditing of electronic call monitoring had not enabled management to identify some staff were logging into 2 calls simultaneously and not recording any travel time between care calls. Where concerns about the quality or safety of people’s care had been identified, prompt action had not always been to improve people’s care and ensure their safety. For example, following one person’s unwitnessed fall, their care plan and risk assessment had not been reviewed and updated.

Staff and management we spoke with told they collaborated with all relevant professionals, stakeholders and agencies, such as district nurses and occupational health therapists. However, management were unable to explain how they had liaised effectively with the relevant teams and professionals to resolve the lack of information in people’s care plans following hospital discharge.

Processes were in place to ensure external partners were notified of relevant information. For example, the management team completed CQC notifications, based upon information brought to their attention and had raised safeguarding concerns with the local authority safeguarding team. However, ineffective incident and accident reporting processes impacted the sharing of information with partners. Systems and processes had not ensured consistent effective collaboration with relevant external stakeholders regarding the lack of information and guidance in people’s care plans following hospital discharge.

People and relatives told us staff assisted them in arranging support from other healthcare services as needed.

Staff understood how to make improvements to people’s care happen, by, primarily, raising issues and concerns with the management team. However, the management team did not demonstrate a clear awareness of how to drive improvements in people’s care and minimise risks to people and others. The management team explained they involved people and their relatives in improving the service through care review meetings and conducting periodic care surveys. However, we found care reviews were inconsistent. The management team were not always able to tell us how learning was shared when things went wrong. Conversations with staff did not demonstrate that they were supported to prioritise time to develop their skills for improvements in people’s care. Staff felt they could raise suggestions and concerns and were confident these would be listened to and acted on by management.

Systems and processes to support learning and improvement in people’s care were not effective. Incidents and accidents were not consistently reported and, when reported and investigated, learning from these safety events was not consistently identified or shared with staff. Staff were not always appropriately supported to develop their skills and knowledge to contribute to safe and effective care. This included a lack of staff training in relation to people’s individual health needs.