South Manchester Care Limited

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 good. 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 regulation in relation to safe care and treatment.

This service scored 25 (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. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. As a result, opportunities to improve practice and reduce the risk of future harm were missed.

Safeguarding incidents were poorly recorded, inconsistently escalated and not effectively audited. Where reviews took place, the outcomes and learning were not consistently shared with staff. Some staff told us they attended meetings where lessons learned were discussed. However, other staff told us they were unaware of any safeguarding incidents within the organisation. This demonstrated important information was not communicated consistently across the workforce.

Records showed meeting minutes were not routinely produced or shared. Instead, information was communicated through an online platform group, which not all staff could access. This increased the risk staff would not receive important safety information and organisational learning.

The provider did not consistently learn from incidents. For example, records did not clearly state how many staff should accompany a child in a swimming pool to ensure safe support. Incident debriefs were not routinely completed. As a result, potential triggers, contributing factors and effective behaviour support strategies were not consistently identified or used to reduce the likelihood of future incidents.

Evidence gathered from records and feedback from relatives, staff and professionals demonstrated a lack of provider-level oversight and understanding of incidents. This limited the provider's ability to identify trends, implement improvements and ensure people received safe care.

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.

Most relatives told us there was insufficient continuity of care. They described frequent changes in care staff, carers arriving late and occasions when carers did not attend. This negatively affected children who relied on consistency, routine and familiar staff to meet their needs safely. One relative told us staffing was unreliable they said “A rough idea would be a quarter of the time the days are cancelled. Or if just one carer turns up and I hadn’t planned going (on a community activity), I do step in though I should not have to.”

Records showed the provider had advocated for one person to continue receiving support from two carers at all times to maintain continuity of care. However, records also documented improvements in the person's sleep routine, suggesting this level of night-time support may no longer have been required. The provider had not discussed this change with the relevant local authority. This demonstrated a lack of ongoing review and communication with partner agencies to ensure care arrangements remained appropriate and reflective of people's needs.

The provider did not work well with people and partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider did not consistently identify safeguarding incidents. Incidents were either not escalated or were not escalated in a timely manner. This prevented concerns from being investigated promptly and reduced opportunities to undertake root cause analysis and identify learning to prevent recurrence.

When we reviewed one child's daily records, we identified three separate incidents which had not been escalated as safeguarding concerns. When we raised this with the provider, they told us they had identified these concerns during the same week and planned to meet with the family the following week. However, they had not reported the concerns to the relevant local authority at the time of our assessment.

Concerns about safeguarding had also been raised externally. One local authority had ended all care packages with the provider due to safeguarding concerns. Two further local authorities told us they had experienced delays in receiving important information from the provider.

The provider did not consistently share safeguarding learning with staff. Some staff told us they attended meetings where lessons learned were discussed, while others stated there had been no safeguarding incidents within the organisation. This inconsistency demonstrated safeguarding information was not effectively communicated.

There was limited evidence lessons from safeguarding incidents had been embedded into practice. For example, records still did not clearly specify how many staff should accompany a child in a swimming pool to ensure safe care and support.

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 which mattered to them.

Records we reviewed showed numerous incidents involving people displaying distressed behaviours, including episodes of aggression which resulted in injuries. Two people had attempted to injure members of the public. These risks were not clearly reflected within their risk assessments.

Risk assessments instructed staff to use de-escalation techniques and positive behaviour support strategies. However, they did not clearly describe what these interventions involved or how they should be implemented. This limited staff's ability to respond consistently and safely to incidents.

Staff experienced injuries while supporting people. However, incidents were not adequately explored to identify causes, risks or preventative measures. Staff did not receive sufficient support following these events. As a result, opportunities to reduce the risk of future harm to both people and staff were missed.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider did not maintain records of daily environmental checks identified within risk assessments. They also failed to maintain accurate records relating to the servicing and safety of equipment, despite this being required by their Equipment Maintenance Policy.

Daily records for one child identified concerns a hoist was becoming stuck during use. Carers also noted the hoist's service date had expired. This increased the risk of equipment failure and avoidable harm. We reported this to the local authority and to the provider. The provider advised they had made an appointment to meet with the family and were going to raise this with the local authority.

Daily records also documented incidents where staff were assaulted in the community and while driving. In one incident, a staff member's seatbelt was unfastened during an assault. Some, but not all, incidents had corresponding incident reports. Where reports had been completed, managers had not recorded debrief discussions or actions taken in response.

These failures demonstrated a lack of effective safety oversight and exposed people and staff to avoidable risks.

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. They did not work together well to provide safe care that met people’s individual needs.

The provider did not operate robust recruitment procedures. Required pre-employment checks were not always current and, in some cases, had been obtained from previous employment rather than verified by the provider. Interview records did not provide sufficient assurance applicants possessed the skills and experience necessary to support people safely. References were not always obtained from the most recent employer and some recruitment files contained only character references.

We raised these concerns with the provider, who told us they had reviewed and updated recruitment records. However, during our return visit we reviewed two additional recruitment files and identified further recruitment concerns. This indicated the provider had not taken effective action to address identified risks.

The provider told us new staff received a two-day induction and several days of shadowing. Staff feedback was inconsistent. Some staff described positive induction and shadowing experiences. However, others reported receiving little or no practical support before working alone. One staff member told us, "(There was) No shadowing, I went to visit (child) on my first day. I felt nervous, I'd not done that sort of work before." Another staff member told us, "The induction its basically non-existent. More a case of getting uniform and sent to a care package straight away."

Relatives also raised concerns about staff competence and consistency. One parent told us a carer supporting another family member undertook an aspect of care which South Manchester Care Limited staff could not provide. Another parent told us, "(Child name) medication is just a tablet, but they said (carers) they're not allowed to give them medication as they are not nurses…At first they gave tablets, but they were told by the office that they can't.”

Training records showed gaps in staff training in essential areas such as autism and learning disability. These findings did not provide assurance staff possessed the knowledge, training, skills and support required to deliver safe and consistent care.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. They did not advise the CQC of a recent incident which could affect wider staff members and people supported.

During the assessment concerns were raised by Public Health that a staff member worked with active respiratory symptoms and disease for 3 months with close prolonged contact with vulnerable people. Public health raised concerns as the provider has not been able to reliably identify all children and other staff members the sick staff member worked with. This resulted in nurses going into the service and more children and staff were identified.

The provider's infection prevention and control policy contained outdated information on current organisations and did not provide staff with clear, current guidance. For example, it contained an overemphasis of Covid 19.

One parent had asked a carer to do a deep clean of their home rather than provide care for the child. The carer had declined and the parent said the provider had said the staff would do this task. This raised concerns about whether staff responsibilities and infection prevention arrangements were clearly understood.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider's records showed no medication errors and recorded 100% compliance across completed audits. We found this did not reflect practice. Although staff had completed training, competency assessments and medication spot checks, medication administration records (MARs) were incomplete as they did not contain the required signatures.

We found medicines prescribed for one person had not been administered because they were unavailable. The provider had not identified this omission through their monitoring systems and had not sought advice from healthcare professionals regarding the potential impact of missed doses. Given the potentially fatal consequences associated with the person's condition, this placed them at significant risk. When explored by the provider it transpired this had been raised with external professionals but had not been recorded by staff.

The provider's auditing systems failed to identify these concerns, which meant people remained at risk of harm from unsafe medicines management.