Sagecare (Surrey Court)

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. This is the first assessment for this newly registered service. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed.

The service was in breach of legal regulations relating to notifications and records. CQC had not been notified of all suspected safeguarding incidents and people’s records were not sufficiently comprehensive to ensure safe care.

This service scored 53 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had processes in place for staff to report incidents and near misses. This included reviewing and learning from incidents and adjusting people’s care accordingly to keep them safe. Staff confirmed they would report any concerns to the office straight away.

The provider did not always work effectively with people or with healthcare partners to establish and maintain safe systems of care. Staff did not consistently monitor or manage people’s safety and did not always ensure continuity of care, including when people moved between services.

The provider did not always support people to transition safely into the service, including from hospital. One relative told us, how a person’s coming home from hospital was poorly managed and staff were not available to meet them when they arrived back home.

The service did not always complete comprehensive assessments with people and their representatives when they returned from hospital. Records showed staff had not updated care plans, leaving incorrect information on people’s files and failing to guide staff on changes to people’s needs. We raised these concerns with the management team. They told us following our feedback they met with the person and their relatives to update the care plan, so it reflected their current support needs. Leaders also informed us they will be introducing more comprehensive checks to prevent this happening again.

The provider did not always work effectively with people or healthcare partners to understand what being safe meant to individuals or how best to support them to achieve this. They did not consistently focus on improving people’s lives or protecting their rights to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, or neglect. The provider did not always share concerns promptly or appropriately.

The provider reported safeguarding concerns to the relevant authorities and cooperated with investigations. However, they did not always notify CQC promptly, as required by law. For some incidents, the provider told us they were waiting for more information from the local authority before submitting a notification. However, notifications must be sent without delay and updated once further information was available to ensure CQC could monitor if appropriate action was taken.

Staff had received safeguarding training. They were confident in recognising and responding to safeguarding concerns, including concerns relating to self‑neglect when people declined care.

The provider aimed to work with people to understand and manage risks, but staff did not always record these risks clearly. Staff assessed risks related to personal care, moving and handling, and people’s health conditions. However, care plans did not always describe how staff should support people to reduce the risk of harm. As a result, staff did not always have clear guidance on safe practice. For example, they did not consistently or accurately record people’s risks relating to eating and drinking.

In two people’s files, staff recorded conflicting information about whether they required a soft diet and whether a health professional had assessed their swallowing needs. This inconsistency increased the risk of unsafe support.

Some people and relatives told us they were concerned about mealtime risks, including food not always being cooked properly and staff not consistently providing suitable meals. The provider told us they planned to speak with staff and deliver cookery sessions to improve understanding of safe food practices. They also introduced a food preparation guide for staff to develop their confidence in preparing meals which meet people’s needs.

Despite gaps in documentation, most staff demonstrated a good understanding of how to support people safely.

The provider did not consistently identify or manage risks in the care environment, and they did not always ensure equipment, facilities and technology supported the safe delivery of care.

Some people did not feel safe in their homes. One relative told us, “There have definitely been times when I’ve felt care isn’t safe. I have to follow them doing a lot they should be doing, for example wiping up the bathroom floor so it’s not left as a trip hazard.”

The provider completed home environment assessments to identify and reduce risks, but these assessments were not always robust. For example, fire risk assessments for people who smoked lacked sufficient detail. P Personal Emergency Evacuation Plans (PEEPs) were not updated to reflect the support people would need during a fire.

Records for people using equipment did not always list all equipment in use. For those using manual handling equipment, including hoists, records did not show when the equipment had last been inspected or when it was next due for review in line with health and safety legislation. Some entries stated, “doesn’t know when last updated.” This meant staff did not have all the information they needed to confirm equipment was safe to use.

Leaders told us they were reviewing all care plans to ensure they contained clear, detailed and up‑to‑date information to support staff.

The provider did not always make sure all staff received effective support, supervision and development. They did not always deploy staff effectively to ensure people experienced care from consistent staff. People and relatives told us they did not always receive care from familiar workers. Call times varied, and some people experienced late or rushed visits, leaving them waiting for personal care.

People told us they previously had regular staff, but this had changed and they now received support from many different staff members. One person said, “I have lots of different carers and that is very difficult when the care is so personal,” explaining this caused them stress because they did not know who would be visiting. Another person requested a rota, so they knew who to expect, but this was not maintained. People also said staff often arrived late, apologised for delays, and then left early to catch up. One person told us, “Time keeping is not good, they are always apologising for being under pressure.”

Staff received relevant training, and systems were in place to support learning and development through supervision, competency checks, and team meetings. However, some records showed these systems had fallen behind. The provider told us this was improving following the appointment of a new manager. Staff were recruited safely.

The provider took action during the inspection to address these concerns. They told us they would allocate a core team of care staff to each person to ensure they received care from a consistent staff team.

The provider had infection control policies and procedures in place to support staff to maintain safe standards of infection control. However, some relatives raised concerns about poor food hygiene practices, including out‑of‑date food not being checked and water bottles not being washed properly, which could increase infection risk.

Most people told us they had no concerns about infection control and said staff wore appropriate personal protective equipment (PPE) during care. Staff told us there were always sufficient PPE supplies available, enabling them to follow good hygiene practices in people’s homes.

The provider did not ensure medicines and treatments were consistently safe or delivered in line with people’s needs, capacities, and preferences. Staff did not always involve people in planning their care. Although the provider had medicine policies aligned with national guidance, staff did not always follow these when administering medicines. This increased the risk of medicine errors. For example, people’s ‘when required’ medicine records did not state why they required the medicine and how it should be administered as prescribed.

Records for people prescribed topical creams were often unclear. These did not always specify where creams should be applied, and at times staff recorded applying two different creams to the same area, placing people at risk of harm.Medicine administration records contained gaps and did not show people had received their medicines as prescribed. Time limited medicines did not include start and end dates, and records showed some doses were missed or administered after the course should have finished.People and staff expressed concerns about medicine safety. One relative reported a member of staff applied an entire tube of cream intended for sparing use during a single visit.

People’s medicine risk assessments were not robust or clear to ensure for example, for one person the risk assessment stated they did not have any PRN medicines when they had a PRN cream applied. Although staff had received training in medicines management, the provider could not demonstrate all staff had been assessed as competent to administer medicines safely in line with best practice. Some staff told us these competency assessments were overdue.

The provider told us they had recently identified these concerns and had begun taking action. They had developed an improvement plan that included additional staff training. They had also appointed two medicines champions, due to start in mid‑January 2026, who would carry out weekly audits of stock levels and documentation to ensure people received their medicine as prescribed.