Sambhana Care Ltd

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

We assessed all the quality statements at this assessment. We found the quality of the management of the service had deteriorated and there was now a breach of regulation. The previous registered manager had left the service in May 2024 and a new manager was in post. We found there had been a distinct decline in the oversight and management of the service. There were no effective systems in place to audit the quality of the service, monitor the quality of care staff were providing and identifying and managing potential risks. The manager had not given opportunities to people, relatives and staff to provide feedback about the service. Complaints had not been investigated fully and there was no evidence of how decisions were made.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had not put any systems, such as surveys, in place to ensure the culture of the service was what they wanted it to be. Staff told us they liked working for the provider and were happy in their roles.

The provider had not ensured effective systems and processes were in place to provide assurance that people received safe care and treatment. Staff did not receive adequate supervision or oversight to check their practice when providing care and support to people was safe. The systems and oversight of how incidents were reported and managed was ineffective. When complaints and concerns were raised by people and relatives, or stakeholders, the provider did not review information to identify repeated patterns which meant people were exposed to further harm. There had been instances of staff providing allegedly poor care and these incidents were not investigated to provide assurance poor practice was not more widespread among the staff team exposing people to harm from unsafe practices. Staff had not received the appropriate guidance or training to ensure an open culture of reporting and learning lessons was embedded in the service. This placed people at risk of being supported by staff who used unsafe practices.

Staff we spoke with told us that the provider was accessible and available when needed. Feedback on the new manager in post was generally positive, telling us they were “cooperative and approachable.” However, the provider did not ensure allegations against staff were fully investigated to ensure processes were fair and equal for all staff. There was a risk poor practice could continue placing people at risk of harm.

Leaders at the service including the provider and service manager failed to lead by example. There were significant shortfalls in risk management and mitigation, and incidents and concerns were not investigated to reduce the risk of a re-occurrence, placing people at risk of harm. Concerns we raised to the management team had not been considered or not known or identified through their processes and systems. Staff were not fully supported to make sure they were providing safe support, and to make sure they had the opportunity to raise concerns or worries. Leaders did not demonstrate they were capable, open and transparent. Incidents had not been investigated, complaints had not been fully responded to, and people’s care records did not contain sufficient detail which meant they could not be assured people received safe care.

Staff we spoke with felt able to raise concerns but each one told us a different process. Some said they would use the WhatsApp group, some told us they would call an emergency number, speak with supervisors or contact the provider. It was clear from speaking with staff that they were not clear on what the procedure was. All staff told us however, that they would feel able to raise concerns with the service. However, staff were not able to tell us where else they could go in the event they did not feel comfortable to raise a concern.

We could not be assured processes to ensure staff understood their responsibilities in sharing concerns were effective. Concerns had not been raised by staff. However, staff had not had supervisions or observational checks on their care practice. Staff meetings had not been held regularly so there was limited opportunity for staff to have direct contact with leaders. Staff had been dismissed following allegations of unsafe and poor care. However, the concerns had not been investigated to learn lessons, identify what went wrong and if other staff had been aware of concerns and had not reported them.

The provider told us the service has been recognised as being able to deliver good support to ethnic minority groups such as people who are from an Indian background. They said the local acute trust had discovered a barrier to people from this background accessing care and now contact Sambhana Care direct as they can offer carers from a similar cultural background. Staff felt the workforce was equal and diverse. Many staff were from a ethnic cultural background and they were allocated to work with people who shared this. This has been a source of positive feedback from staff as they are able to support people in an individual way whilst respecting their cultural and religious beliefs.

There were no processes or policies in place to make sure people had a choice of who supported them. While the provider was recognised for supporting people from an Indian background, with staff who shared this culture, there were very few other staff from other backgrounds. There was a risk not all people would have the choice of support from staff who would understand their cultural or language needs.

During the first day of our assessment visit we were told that the new manager could not find any audits the previous manager had completed for review. The new manager told us they had not completed any audits since starting at the service. The provider had not completed any check or audits on the service during the time of the previous registered manager leaving or the new manager starting. The provider had employed a compliance manager in April 2024 who identified issues within the governance of the service including care plans not being detailed and no risk assessments, but they could not tell us what had been done to rectify or address these concerns.

The provider did not have a robust system in place to effectively monitor and continuously improve the service they provided. No effective audits had been completed since our last assessment in January 2024. We found a number of concerns that had not been picked up or actioned by the provider including the lack of care plans and risk assessments, no accident and incident recording and monitoring, safeguarding concerns not reported to the local authority and CQC, as well as staff training and supervision and staff recruitment. Although a member of the management team had raised their concerns to the provider about the lack of practical moving and handling training for staff, no action had been taken to rectify this. They had also raised their concerns about new staff starting to provide care without the appropriate disclosure and barring service checks, no action had been taken. The recently recruited manager was aware no audits had been completed, peoples’ care records were inadequate, people’s care had not been reviewed, and staff had not been appropriately supervised to ensure their competence and people’s safety. However, they nor the provider had taken any immediate action or developed a plan of action with priorities based on people’s safety.

Relatives told us, they were not clear about processes to report health concerns, staff did not think it was their responsibility. They told us, “One thing they don’t do, I don’t know how it works, community nurses told me, if they have bed sores, they have the palliative care team number and they should raise it with them, it goes to local hospital and they send out nurses, it seems to be that I am always calling them, they see them so the carers should call, I’m struggling a little bit with that. I told supervisor they should ring, and he questioned it. That’s what I am being told. I don’t know how it works”.

The provider and manager told us they had good relationships with healthcare professionals and funders.

Partners who fund packages of care told us they had received mixed feedback from people and their relatives regarding the care and support they received from this provider.

The provider was not always open and transparent with external stakeholders and agencies. We identified 3 incidents that had not been reported to the local authority and those incidents had not been reported to CQC.

The provider was receptive to the concerns we identified during our assessment. During the second day of our visit the manager started to call people using the service to seek their feedback on the service being provided. However, they had not identified any learning or how to plan the action they needed to take to make improvements until we pointed out the concerns we had and the areas that should have been addressed.

There were significant and widespread concerns identified during this assessment. There were no processes in place which were clear or a structure that enabled the provider to learn from any incident or accident or event within the service. The provider could not evidence action had been taken to learn and improve the quality of the service. There was not a consistent approach to measure outcomes and impact for people. There was no evidence that the manager and provider reviewed best practice. There was a lack of understanding around risk management and oversight, and opportunities to implement improvements had been missed. When things went wrong there was a lack of leadership, oversight and investigation from the provider, this placed people at risk of continued poor practice by staff and incidents happening again.