Sagecare (Surrey Court)

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• 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 newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation governance due to internal quality and risk monitoring systems not identifying shortfalls in the service.

This service scored 54 (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 shared vision and strategy aimed at promoting transparency, equity, equality and human rights, diversity and inclusion, engagement, and an understanding of people’s needs and the challenges within the local community.

However, throughout the inspection we found the provider had not achieved their aims for all people. Everyone using the service had not received person centred care of a high quality.

Staff understood the aims and values of the organisation. Management told us they discussed these values as part of the induction process for new staff to ensure they were embedded from the outset.

Not all leaders understood the context in which the provider delivered care, treatment, and support. Leaders did not always have the skills, knowledge, experience, or credibility needed to lead effectively, or did not always do so with integrity, openness, and honesty.

We identified breaches of legal regulations and concerns about records and governance, notifications and person-centred care. Leaders had not independently identified or addressed these issues before our assessment and some development was required.

The service had been without a registered manager and a team leader for a prolonged period. As a result, staff told us they felt unsupported, and people said communication had been poor and the quality of the service had declined. A new manager had recently been appointed and had started their application to be registered with CQC. A team leader from another service was providing temporary support until recruitment was completed. The provider was also recruiting a care manager to strengthen leadership and improve outcomes for people. The manager was being supported by an area manager, the head of quality, and the director of homecare, all of whom we met during the inspection.

The provider was working to establish a culture where people felt able to speak up and confident that their voices would be heard. However, the service had gone through a period when the culture had deteriorated due to a lack of management support. The service was now with a management team on site and were making improvements to improve the culture of the service and where people could feel able to voice concerns.

Whistleblowing policies and procedures were in place, and staff understood how and to whom they could raise concerns. The provider also offered a confidential reporting system through its intranet, which staff could access at any time. Whistleblowing concerns raised through this system were reviewed by an external company, providing an independent and safe route for staff to report issues.

Staff we spoke with told us they felt comfortable speaking up on behalf of people. They said they listened to people’s needs and acted on any concerns or issues raised.

The provider did not always value diversity within the workforce. They did not consistently promote an inclusive and fair culture or take effective action to improve equality and equity for staff.

Policies and procedures to promote equality and diversity were in place, and senior managers met with staff to gather feedback and understand individual needs and circumstances. However, not all staff felt the culture was fair or equality was promoted across the service. One staff member told us, “Equality and diversity concerns have been raised repeatedly with no action taken.”

The provider did not have clear responsibilities, roles, or systems of accountability to support good governance. Leaders did not act on the best available information about risk, performance, and outcomes.

The provider’s quality assurance processes had not identified all the concerns we found during this inspection. This included for example concerns relating to medicines management, care planning and review, notifications, person centred care and inconsistent staffing. Audits were not robust to identify and improve shortfalls before they impacted on people’s care.

Although a quality team carried out audits, these did not include reviewing care for people returning from hospital or checking whether people were consistently treated with dignity and respect. This raised concerns about the robustness and effectiveness of the audit process. The provider told us they visited the service weekly to support improvement and had begun acting on our findings.

The provider understood its duty to collaborate and work in partnership so that services operated seamlessly for people. Leaders shared information and learning with partner organisations and worked collaboratively to drive improvement.

The leadership team and staff worked effectively with health and social care professionals to meet people’s needs. Staff worked with relevant healthcare professionals when people’s health needs changed and made referrals to occupational therapists, community nurses and GPs when required.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The service aimed to promote continuous learning and improvement across the organisation and local system. However, during the inspection we identified several concerns, which we highlighted throughout this report. Although the provider was motivated to learn and improve, they were limited by the lack of effective risk and quality monitoring systems. This meant leaders were not always aware of shortfalls and could not consistently act promptly to drive improvement. Despite this, the provider responded quickly to the issues we identified during the inspection and began implementing improvements, including strengthening involvement in people’s care and medicines. They shared an action plan with us outlining areas for development and the steps they intended to take.