SQ Carers Ltd

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 requires improvement. This meant people were not always safe and protected from avoidable harm.

The service was in breach of legal regulation in relation to safe and effective staffing at the service.

This service scored 44 (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. Staff did not listen to concerns about safety and did not always investigate and report safety events. Lessons were not learnt to continually identify and embed good practice.

Safety incidents were not always recorded in detail, and there was limited information about what actions had been taken as a result to mitigate the risk of reoccurrence. For example, 1 person had sustained a fall, but the cause of how the fall happened was not recorded in their care plan. The person’s moving and handling risk assessment had not been updated following the fall, and there was no information to inform staff how to mitigate the risk of reoccurrence. This meant learning from incidents had not been used to inform safe practices.

The provider’s electronic care call system did not always record the correct location staff signed in from. Staff told us they had reported this issue to the registered manager. We identified this issue at our previous inspection in 2019, yet the issue remained. This created an excessively high number of ‘system alerts’ that went without proper investigation. The high volumes of alerts had become an issue to keep in control of. One remedy the provider took was to get an external company to close the alerts without any proper analysis or assurance people’s care calls had been completed. This meant opportunities to learn and improve practice went without investigation.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Staff were able to recognise and escalate concerns regarding people's changing healthcare needs however; systems were not always robust enough to ensure referrals were followed through in a timely manner. A relative described an occasion when care staff identified changes in their family member's skin condition and appropriately reported these concerns to the office. Staff contacted the registered manager to request support from the district nursing team. However, the referral was not passed on as expected, resulting in the person experiencing a delay of almost 1 week before receiving the anticipated nursing support. This demonstrated a breakdown in communication and oversight arrangements, placing the person at risk of delayed treatment and poorer outcomes.

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

Safeguarding processes were not effective in ensuring concerns were identified, reported and escalated appropriately. Not all staff were aware of their safeguarding responsibilities. Daily notes, recorded by care staff, contained information which should have been flagged for safeguarding consideration. There was no detail on whether concerns had been highlighted to the registered manager or what action had been taken as a result. We discussed this with the registered manager who told us they had taken some action, but this had not been documented. This did not demonstrate safeguarding procedures had been fully followed. We asked the registered manager to raise a safeguarding concern with the local authority immediately following our visit. We checked our records and the provider had informed us they had raised a safeguarding with the local authority, but it took them 7 days to tell us. In the meantime, we raised a safeguarding to help ensure people were protected. Staff told us they had received safeguarding training, and they knew what to do to report any issues, however records of the incident we saw implied, staff had not taken any action as agencies or us were not informed.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Processes for identifying, assessing and managing risks were not always effective. Care plans did not consistently identify risks to people or provide clear up to date guidance for staff on how risks should be managed safely. People’s care records lacked accuracy which meant staff did not always have access to the information required to deliver safe and effective care.

For example, 1 person’s care records referred to ongoing wounds requiring support from healthcare professionals. The registered manager told us these wounds had now healed, and care staff were providing preventative care to maintain skin integrity. A risk assessment to establish this person’s risk of skin breakdown, had recently been completed by a member of staff, and evidenced the person was at very high risk. When we asked the member of staff who had completed the assessment if the wounds had healed or not, they stated they did not know and would need to speak to care staff for accuracy.

Another person's health needs had changed significantly, and care staff had recorded within daily observation notes the person had a medical device fitted to administer pain relief and support their comfort. However, this information had not been incorporated into the person's care plan. Risks associated with the device and the person's changing healthcare needs had not been assessed or documented, meaning staff did not have access to clear guidance on how to support the person safely. A third person required a modified diet and thickened fluids. Despite the known risk of choking, an appropriate risk assessment had not been completed and had not been used to inform care planning. Following our visit, the registered manager sent us information for the person on a modified diet. However, the information we were sent contained conflicting information, so it was not clear how staff needed to safely support this person.

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

People’s safety within their home environment had been considered and assessed. Risk assessments identified environmental risks and provided guidance for staff. For example, 1person’s assessment detailed the location of emergency cut off points for gas and water supplies and identified the position of the carbon monoxide tester. This helped support staff to respond appropriately in the event of an emergency. However, it remained unclear what processes were in place for staff to share environmental concerns or what action was taken when there were concerns with equipment. For example, in 1 person’s care notes, staff had recorded ‘screw loose on wheelchair,’ but with no further detail on what actions were taken to ensure this was made safe.

People’s care plans did contain some information to inform staff, how to manage some environmental risks, such as trips, falls, and issues within the home environment. There was information for staff to report any unsafe equipment, but we could not see any records to show, the office staff had been informed of the safety of the wheelchair we referred to.

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.

Almost everyone we spoke with said there were not enough staff because their care calls were not at the times they needed. One person told us, “The carers (staff) are meant to stay for 45mins although 2 out of 7 days they usually stay for 30 minutes which is not time enough to give me a shower.” Another person said, “I have 2 carers (staff) 4 times a day, and their hours are all over the place. I don’t have the same staff 2 days in a row. If things go smoothly whilst they are with me, they go early, sometimes they may stay longer, over the week they owe me time.”

The provider’s systems to manage when care staff arrived and left a care call, was not reliable. Care call data shared with us from the local authority showed a high number of care calls were not always at people’s preferred times. In some examples, it was 90 minutes later than planned. Some people’s care calls showed staff logged in over 300kms from the care call. Despite, this being a known issue we had raised at our inspections in 2019, but there was no reasonable answer given to why this had not been addressed or how it was going to be remedied.

Staffing arrangements did not always ensure people received care from suitably recruited, trained and competent staff. Safe recruitment processes had not been consistently followed.Staff files did not contain sufficient detail to show they had been recruited safely. There was no recorded evidence the provider had completed Disclosure and Barring Service (DBS) checks for 2 staff files we reviewed, in line with regulatory requirements. The registered manager was later able to locate these on their phone. Recruitment records were held across numerous electronic devices and not in one place. This made them difficult to check. Not all staff files contained sufficient references to demonstrate employed staff were of good character to work with vulnerable adults. A member of staff, present on the day of inspection, told us some references had previously been removed from files, and they were unable to replace them. No induction records were available to us to view during our inspection.

Other staff were employed on a sponsorship licence. The provider had since had their licence to employ staff on a sponsorship revoked, and staff had found alternative sponsors. The provider continued to employ these staff on zero-hour contracts, which they are entitled to do, but could not show us evidence they had obtained alternative sponsorship and therefore had a right to legally work. Some staff were employed through an agency. We could not access their employment profiles. The registered manager told us they held these records on their laptop, which was not functioning on the day of our inspection. Staff spot checks were completed. Records showed these had not taken place since May 2026. This was confirmed to us by a relative who told us they have stopped happening recently. We saw some completed spot checks did not records people’s feedback about their care.

Throughout our inspection we saw alerts related to care call log ins and log outs had been signed off by staff who were no longer employed by the service. The registered manager could not explain how or why this was happening, whether they still had a log in for the system, or if someone else was doing so under their name.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control (IPC) practices were not always supported by detailed care planning. Care plans did not contain sufficient information to guide staff how to follow best practice and minimise the risk of infection. For example, 1 person had a catheter and a stoma. Although these were both documented in the person’s care plan, there was insufficient information on what actions staff needed to take to minimise the risk of infection, what signs may indicate there was an infection or how this may need to be escalated. Guidance for staff was to ‘advise family if there was a concern.’ This meant the provider could not be assured staff were working in a way that promoted good IPC practice, or they knew how to respond appropriately if concerns arose.

One relative told us they had shared specific information with the provider regarding infection control measures in their home, including the need to separate soiled and clean linen. Despite this, they reported staff did not always follow these instructions. This meant agreed IPC practices were not consistently implemented, increasing the risk of cross-contamination. Staff consistently recorded they wore appropriate PPE when delivering care to people and told us PPE was made available to them when they needed. One staff member said, “We must change our gloves between all tasks. For washing, we change gloves, for hoisting, we change gloves and when feeding people, we change gloves.”

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

We found no impact or harm on people; however, people were not always supported to receive their medicines safely and in accordance with national guidance and best practice. The registered manager told us they supported 3 people to administer their medicines. We were told 1 person received their medicines covertly, however the person knew their medicines was placed in food. We found this person needed time critical medicines administered by staff. The person’s MAR recorded these to be given at 08:00am. We found a high number of their care calls were around 09:30am. This increased the risk of medicines being administered in a way that could affect their effectiveness or safety.Some people required medicines to be given before or after food. There was no evidence these were being administered as prescribed, which may affect the way they are absorbed. Some medication administration records (MARs) we reviewed and indicated doses of essential medicines had been missed. There was no evidence these omissions had been identified, investigated, escalated, or reviewed by management. This demonstrated a lack of oversight and increased the risk of people not receiving their medicines as prescribed.