Sambhana Care Ltd

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to people’s safe care and treatment, the ways people’s medicines were managed, safeguarding, staffing and recruitment.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. Lessons were not learnt to continually identify and embed good practice. The reporting, analysis and action taken following incidents or accidents had deteriorated since our last assessment. Some, but not all accidents and incidents, had been recorded on an incident form, however, there had been no analysis to identify any patterns or trends. For example, 1 person had fallen 3 times while they were at home by themselves. The reason for the falls was given as ‘issue while transferring’, there was no evidence this had been investigated or action taken to reduce the risk of this happening again. The manager told us they had contacted the GP about the person’s falls and the GP had a plan, but they did not know what the plan was or how staff could support the plan.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. There were no effective processes in place for staff to follow to ensure when people returned from hospital their support was restarted. There had been an incident where the provider had been informed a person was returning to their home. However, staff were not informed they needed to visit the person. The person was placed at risk as they did not receive the care and they needed for 3 days, until staff were informed. The provider told us there was usually a call from the ambulance crew, but this had not happened. The provider stated that there was no system to make sure the information was communicated effectively. People’s care plans were not sent with people when they went into hospital, this placed people at risk especially when they had complex health needs and could not speak English. There was an increased risk healthcare professionals would not support the person appropriately.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not share concerns quickly and appropriately. There were no effective systems in place to recognise, record and be open about safeguarding concerns. There was evidence of at least 3 significant safeguarding incidents which had not been reported to the local authority for investigation and CQC. A serious incident was only raised with the local authority safeguarding team on the advice of inspectors. When the incidents were reported, the information given by the provider was not detailed, accurate or representative of what had taken place. The provider had not executed their responsibilities to keep people safe, be open and transparent and work with other professionals to reduce the risk of incidents happening again.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Following our last assessment, enforcement action taken required the provider to improve the quality of guidance in people’s risk assessments. Since our last assessment the provider had introduced an electronic care plan system to improve the recording of risks. However, the quality of people’s risks assessments had deteriorated. Potential risks to people’s health and welfare had been identified but had not been appropriately assessed. The risk assessments did not contain detailed guidance for staff to mitigate risk, the same guidance was in place for many of the risks identified. For example, 1 person was incontinent of urine and faeces, the guidance for staff included seek medical advice and complete an incident form. There was no guidance for staff about how to support the person to maintain their skin integrity. People’s care plans did not always contain accurate information about their support and care needs and guidance was not personalised. For example, when people required sensory support, one of the measures was to stand in front of the person when verbally communicating. However, this was included in a care plan for a person who was blind. This was not appropriate, as the person would not be able to see staff lips to help with their understanding. Other people were living with diabetes, but there were no guidelines for staff about how the person would present when they were unwell and what action they should take. This put people at risk of unsafe care and harm.

The provider had completed environmental risk assessments, potential risks had been identified. However, the guidance to mitigate the risks and keep people safe was generated by the electronic system and was not relevant to the person’s environment such as to call for medical assistance for all risks. We could not be assured equipment used by staff to support people including shower chairs had been checked to make sure the structure such as the wheels were safe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. There had been very little improvement since our last assessment. There continued to be poor recruitment processes in place. Staff references had not been checked to make sure, they were accurate as the employment dates did not match with those given to us by staff. There were gaps in employment histories which had not been explored to check the reason for the gap. There were discrepancies in the documentation used to authenticate staff identity, these had not been investigated. Following our last assessment enforcement action required all staff competency to be checked. This had not been completed, less than half the staff had been assessed. We could not be assured the competency documentation completed was accurate or the checks had taken place. The records were generic and did not differentiate between staff, several records were duplicates. Regarding documentation related to staff induction, the records were not complete, and the provider did not know how the induction was recorded and checked. The manager told us the induction was a 3 day classroom exercise. There was no evidence new staff had shadowed more experienced staff to learn how people liked to be supported, or evidence of staff competency had been checked before they began working independently. There was no evidence staff training was monitored to check staff were completing online courses. These courses included essential training such as moving and handling, placing people at risk. The manager told us they provided moving and handling training, however, their qualification to do this had not been renewed. The manager had not attended a course to confirm they remained up to date and competent to provide the training. We could not be assured staff were safe to support people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. People’s care plans did not contain information and guidance for staff to reduce the risk of infection including when people had a catheter. This placed people at risk of not receiving support which promoted infection prevention and control. Staff understood their responsibilities to wear personal protective equipment (PPE) when supporting people. Staff told us they had access to PPE when required.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People’s medicines were managed poorly. The manager told us they did not support people with medicines. However, staff were recording in the daily notes they were supporting people to apply medicated creams and eye drops. Other staff were supporting people with their medicines which had been dispensed in cassettes by the community pharmacist. There were medicine administration record (MAR) charts, but not all the medicines were recorded and there was no record of them being given and by whom. A senior member of staff told us staff had received medicines training, and their competency had been checked. However, most of the records referred to staff who no longer worked at the service. We could not be assured staff were trained and competent to administer medicines, placing people at risk.