Sparrow Health 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service. This key question has been rated requires improvement.

The service was in breach of legal regulation in relation to management oversight and the governance of the service.

This service scored 43 (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 clear shared vision, strategy and culture which was embedded across the service. People told us they felt there was a positive culture and the provider supported them well. One person told us, “I don’t have a bad thing to say about them.” The provider told us they wanted people to feel well cared for and to be treated how they would wish to be treated themselves. They told us, “I show staff directly. Staff and people have seen both me and [member of management team] in practice. They [staff] know we speak to people with love and they know we adore the people we support.”

However, effective processes were not in place to ensure staff followed the provider’s principles. Spot checks of the support people received had started shortly prior to the inspection but had not been completed with the whole staff team. There was no system to monitor which staff were observed or how often these would take place. In addition, there was a lack of understanding of the need to ensure robust reporting and transparency to promote a positive and open culture. This included ensuring concerns were shared promptly with the local authority and the relevant safeguarding teams. This lack of oversight compromised the provider’s ability to identify poor practice, support staff development, and to ensure consistent, safe, and high-quality care.

The provider did not have capable leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills and knowledge to lead effectively and with openness. The provider lacked understanding of the responsibilities of providing a registered care service. They had not implemented robust systems and processes to ensure risks to people’s safety were managed well, to safely recruit staff or to provide staff with appropriate training and supervision. In addition, we identified concerns relating to the lack of robust medicines management processes, and the failure to ensure accidents and incidents were reviewed and used to inform on-going learning. These concerns undermined the safety, consistency, and person-centred nature of care delivery, increasing the potential for avoidable harm or unmet needs.

During our assessment the provider told us people’s care records had recently been reviewed and updated. However, people’s records we reviewed still lacked detail of the support they required and did not always provide staff with a comprehensive picture of the support they needed. In addition, the provider had failed to inform CQC of safeguarding concerns in line with their regulatory responsibilities. This meant we were unable to fully monitor risks in relation to the care and support people were receiving.

There was a lack of understanding of responsibilities within the management team and how the different roles were to fit together going forward. The provider told us they were holding weekly meetings to develop strategies and work on priorities. We found meeting minutes were not maintained to demonstrate how priorities would be met, who would take responsibility and to agree timescales for completion. One set of minutes only recorded, ‘Need staff supervision asap regarding visit times and cleanliness’. There was no record of how these concerns had been identified, who would take the lead on completing supervisions or an agreement of when this should be completed. There was no record of which supervisions had been planned or completed to address the issues identified to ensure effective oversight and support for staff.

Systems to ensure people and staff were able to speak up and their voices heard were not reviewed to ensure learning was taken from any feedback received. The provider told us that due to the size of the service they were able to gather people’s views as they regularly provided their support. However, they had not recorded any views shared at these times. There was no system in place for gathering the views of people and staff in a co-ordinated and systematic way. The provider told us they planned to send out surveys to people and relatives in the near future to gather their opinions.

Records showed there were instances where people had felt able to speak up regarding how the service could be improved. Recently implemented spot checks had identified some people did not always feel staff fully engaged with them during support. This had been addressed with the staff members concerned and feedback provided to those raising the concerns.

Staff told us they felt able to speak to the provider should they have any concerns. However, regular staff meetings had not taken place to provide staff with an opportunity to bring forward ideas or discuss any concerns. Records showed only 1 staff meeting had been held in 12 months. This meeting had been used to pass on some key messages and show staff around the new office facilities. There was no record of staff being enabled to bring forward concerns in the meeting or to discuss potential improvements to the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt respected by the provider. One staff member told us, “I feel all the staff are respected for who they are.” The provider had a policy covering equality and diversity which was available to all staff.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider did not have robust oversight of the service. Audits were not completed to assess the quality and safety of the care and support people received. We requested to see audits and quality assurance systems completed over the past year. The provider told us no audits had taken place. This meant no comprehensive review of the systems and processes had been completed to effectively monitor the service and ensure continuous improvements. Hence, the provider was unable to identify risks, drive improvements, or ensure the quality and safety of care which put people at risk. The provider told us they were aware that audit systems needed to be implemented and were looking to further utilise the electronic system used for care records to support this process.

Systems were not in place to monitor the times and duration of care visits. The provider informed us a report was now available on the electronic monitoring system. However, as not everyone being supported by the service had a care plan in place, the report was unable to give accurate data. A review of the times staff logged in and out of visits showed office staff had completed records retrospectively as staff had not recorded this during the visit. Whilst people we spoke with said they did not have a concern regarding the timings of their care visits, an effective system to monitor this was required to ensure people were receiving their care in line with their assessed needs.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborated for improvement. Professionals supporting people using the service told us it was difficult to obtain information and updates from the provider and information often needed to be requested on a number of occasions. This has led to delays in outcomes and learning from safeguarding enquiries. The provider told us they had appreciated the support they had received from the local authority in making changes to improve the running of the service. However, the provider had failed to fully respond to the concerns identified and the improvements made had not been fully embedded into practice. The provider had acknowledged they needed increased support to manage the service effectively. They had therefore increased the management team, although systems of how the different roles would work together, had not been established.

The provider did not focus on continuous learning, innovation and improvement across the organisation. In January 2025 Surrey County Council Quality Assurance Team identified a number of concerns regarding the safe and effective management of the service. These included concerns in relation to staff recruitment, care records not being comprehensively completed, the monitoring of staff rotas and general management oversight. Despite these concerns being raised, no action plan or clear process had been implemented to address the shortfalls identified. The same concerns were identified during our inspection. We asked to see the providers action plan to make the required improvements. The provider told us they did not have an action plan in place. They told us, “I feel we need to get out of the woods before implementing an action plan”. This response demonstrated a lack of oversight and understanding of the need to address shortfalls in the service to minimise the risk of people receiving unsafe and inconsistent care. Following the inspection, we asked the provider to forward an action plan to lay out how they would make changes in a structured way to meet regulations.