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Archived: Saffron Care Agency Inadequate

Inspection Summary

Overall summary & rating


Updated 14 September 2018

This comprehensive inspection took place between 17 and 30 May 2018, the first day was unannounced. We last inspected this service in September 2017 where it was rated 'Inadequate’ overall. At that inspection, we identified nine breaches of regulation. The Care Quality Commission (CQC) took enforcement action against Saffron Care Ltd and imposed a condition on the provider’s registration. This required the provider to send us fortnightly and monthly reports on the areas of greatest concern and risk. This also included a requirement that the provider must give us information about the actions taken in response to any issues.

We met with the provider to confirm what they would do and by when to improve the service. The number of people who used the service had decreased from 260 to 156 people. The registered manager was receiving support from the organisation who sub-contract packages of care to them and the local authority quality assurance and improvement team (QAIT). Despite this support, this inspection has shown widespread and significant shortfalls, and some deterioration, in the service. The only improvement made, that has had a positive impact, was to staff recruitment.

Saffron Care Agency is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults and younger adults. Not everyone using Saffron Care Agency receives a regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. At the time of this inspection the service was providing care and support to 156 people.

The service had a registered manager who was also the provider. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received concerns from people who used the service, staff and the local authority. In response to those concerns we brought forward this unannounced inspection. Prior to us starting this inspection the local authority placed the service back into a multi-agency safeguarding process due to the concerns they had received. We also shared our concerns with the local authority commissioners and safeguarding team. Concerns related to late visits and people being rushed during their visits, lack of staff training, medicines not being administered appropriately, poor communication and lack of response to complaints, and poor staff attitude.

People who used the service were still not safe. We looked at people’s visit records and found staff were not always recording the time they arrived and left visits. This meant the registered manager could not assure us that visits were being carried out as agreed. We found examples of people being rushed, not getting their full visit time, and care being missed. Incidents that should have been reported as safeguarding alerts had not been sent to the local authority without delay. People did not always receive their medicines as prescribed.

When people’s regular staff were not working, staff who carried out visits didn’t always know people or how to meet their needs. We found examples of staff being expected to use equipment when they had not received appropriate training. This included training in how to put on support stockings, using a hoist, catheter care, and supporting people with their oxygen and nebulisers. Some people told us they felt unsafe. One person said “I have issues relating to my safety and the training or lack of training of carers on using my hoist”.

People told us when their regular care staff were not working, they did not receive th

Inspection areas



Updated 14 September 2018

The service was not safe.

People�s care needs were not met because they did not receive their visits as agreed.

Where risks had been identified action had not been taken to ensure people were safe.

Systems and process in place to prevent abuse were not being operated effectively.

Medicines were not managed safely.

Staff recruitment processes were safe.


Requires improvement

Updated 14 September 2018

The service was not always effective.

Some staff had not received specific training to ensure they were able to meet people�s needs.

Staff did not always receive the support they needed to carry out their role effectively.

People benefited from staff who supported them to manage their healthcare needs by contacting healthcare professionals.



Updated 14 September 2018

The service was not caring.

People could not be assured they would receive care that respected their preferences and what was important to them.

People were not always treated with dignity and respect.

Some staff were caring and people had built good relationships with them. Other staff were not caring towards the people they supported.



Updated 14 September 2018

The service was not responsive.

Complaints were not thoroughly investigated and practice was not changed as a result.

People did not always receive consistent, personalised care and support as staff did not receive enough information about them.

People were placed at risk of inappropriate care and support as care plans were not always updated when their needs changed.



Updated 14 September 2018

The service was not well-led.

People continued to receive a poor quality service because issues were not identified and resolved.

There continued to be a lack of leadership, governance and managerial oversight.

Systems for identifying and managing organisational risks were ineffective.

The provider had failed to send us information, required by law, so we knew what was happening in the service.