Blue Sapphire 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 inspection we rated this key question good. At this inspection the rating has changed to require improvement.

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

The provider was in breach of the legal regulation in relation to people’s safe care and treatment.

This service scored 59 (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 always learn lessons effectively to drive continuous improvement and embed good practice.

Records were not audited in a way that enabled trends and patterns to be identified and monitored over time. In addition, the provider did not maintain a record of lessons learned from incidents. This meant there was limited oversight to demonstrate how learning was captured, shared and used to reduce the risk of similar incidents occurring in the future.

However, the provider had systems in place for recording accidents and incidents. Staff completed accident forms which were submitted to the office, and details were entered onto an electronic spreadsheet. Records included information about the incident, actions taken and any outcomes identified.

Incidents and accidents were discussed during team meetings, which provided opportunities for staff to reflect on events and consider improvements to practice. We saw evidence that changes were made following incidents where appropriate.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People experienced continuity of care because they were generally supported by regular staff who knew them well. This helped staff understand people's individual needs, preferences and routines, enabling care to be provided consistently and safely

The provider had systems in place to communicate important information to staff. Updates about people's care and support needs were shared through the electronic care system and email. Although some staff told us communication could occasionally be affected depending on who they spoke to, there were established methods for sharing information and supporting continuity of care.

People had access to other health and social care services when required. Referrals were made promptly and contact logs evidenced communication with a range of professionals. These arrangements supported coordinated care and when people's needs changed or input from other services was required.

The provider did not always have effective oversight of safeguarding. Lessons were not consistently learned to identify and embed good practice.

There were no safeguarding logs or audits in place to provide oversight of safeguarding activity, and in some cases records did not clearly evidence the outcome of safeguarding concerns. This limited the provider's ability to effectively monitor, review and demonstrate learning from safeguarding incidents.

However, the service had a safeguarding policy in place which provided clear guidance for staff on how to recognise and respond to safeguarding concerns, ensuring people were protected from abuse and harm. A staff member said, "All staff members understand and are aware of signs of abuse and how to escalate to the management team."

Training records demonstrated that staff received safeguarding training. This ensured they had the knowledge and skills required to identify risks and appropriately support the people in their care.

Safe recruitment practices were followed, with Disclosure and Barring Service (DBS) check completed for all staff to help ensure their suitability to work with vulnerable individuals.

Staff demonstrated a good understanding of the people they supported. They knew individuals well, including their needs and preferences, which enabled them to provide safe, personalised care and respond effectively to any safeguarding concerns.

There was a clear paper trail demonstrating that the Local Authority Safeguarding team had been involved in safeguarding matters where appropriate, and relatives had been kept informed of the situations. Records evidenced that relevant professionals were referred to as required.

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.

The provider worked with people to understand and manage risks by ensuring people had care records which included risk assessments to help staff manage risks associated with their care and support. However, we found not all risks had been appropriately identified and some risk assessments were missing. This meant staff did not always have up-to-date information and guidance to support people safely.

People had signed consent to care where appropriate. The provider told us people's capacity to make decisions was considered and discussed as part of the initial assessment process. However, while the provider showed us blank Mental Capacity Act (MCA) assessments, they were unable to provide completed examples. This meant there was no clear evidence that capacity assessments had been carried out where people may have lacked capacity to make specific decisions, or that decisions had been made in their best interests in line with the Mental Capacity Act 2005. As a result, the provider could not demonstrate that decision-making processes were consistently supported by appropriate records or that people's rights were fully protected.

People and their relatives were involved in discussions about their care. We reviewed records which demonstrated people and those important to them had opportunities to contribute to care planning and decision-making. This helped to ensure people's views and preferences were considered when planning their care and support.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

As a domiciliary care agency, the provider was not responsible for the upkeep of people's homes. However, environmental risk assessments were in place and provided staff with guidance on managing risks when supporting people in their own homes. The provider had also considered fire safety risks as part of people's care planning.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider followed safe recruitment practices. Recruitment records generally contained the information required to support safe recruitment decisions, including appropriate references and Disclosure and Barring Service (DBS) checks. However, some staff applications did not contain a full employment history. During the inspection, the provider acted promptly to address this and sought complete work histories from the relevant staff members.

There were sufficient numbers of staff available to meet people's needs. People who required support from two care workers received this as planned. Staffing rotas demonstrated that care visits were adequately covered and showed staff worked within national guidance on working hours, helping to support staff wellbeing and the delivery of safe care.

Staff received training relevant to their roles and the needs of the people they supported. This helped ensure they had the skills and knowledge required to provide safe and effective care. One person said, "Staff are well trained and they know what they are doing."

Staff were supported through regular supervision and annual appraisal processes, which provided opportunities to discuss performance, learning needs and professional development.

New staff completed an induction and were given opportunities to shadow experienced staff before working independently. This helped them become familiar with people's needs and the provider's expectations.

The provider carried out competency assessments for all staff to ensure they remained competent and able to deliver care safely.These arrangements helped support staff to deliver good quality care and meet people's needs effectively.

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.

The provider did not have a system of IPC audits to provide oversight of infection prevention and control arrangements and identify areas for improvement. This meant the provider could not be fully assured that staff were consistently following IPC procedures when delivering care in people's homes. Whilst we did not identify any evidence of harm, the lack of formal auditing increased the risk that poor practice may not be identified and addressed in a timely way, placing people at potential risk of avoidable infection. As a result, governance arrangements relating to infection prevention and control were not fully effective.

However, the provider did have an infection prevention and control (IPC) policy and staff had completed relevant training. Staff demonstrated an understanding of infection prevention and control procedures, including effective hand hygiene practices and the appropriate use of personal protective equipment (PPE). People told us staff wore PPE when providing support, which helped to reduce the risk of infection transmission. The provider also carried out spot checks of staff practice.

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

People had Medication Administration Records (MARs) in place which were completed and signed by staff, providing a record of medicines administered. The provider had a medicines policy in place and staff received medicines training and competency assessments before administering medicines. This helped to ensure staff had the skills and knowledge to support people with their medicines safely. Staff told us that they had their medicines competence checked every 3 months during their spot check.

However, we identified areas where the management and oversight of medicines required improvement. There were no protocols in place for medicines prescribed on an 'as required' (PRN) basis. Staff did not have guidance to support consistent decision-making about when these medicines should be given. Records also did not consistently document the reason for administration or the outcome of the medicine. This increased the risk that PRN medicines may not be administered consistently in line with people's needs and preferences. However, staff knew people well and people felt safe and happy with the care they received. One person said, "They give my medication as well, they know things and they help me."

The provider did not carry out regular medicines audits. This meant there was limited oversight of medicines management and reduced opportunities to identify errors, trends, or areas for improvement.

We found an example where medicines were not always administered in accordance with best practice. The provider had not sought appropriate guidance to support the medicine administration process. During the inspection, the provider took immediate action to address this and sought professional advice. The person's family and staff were informed to help ensure medicines could be administered safely and consistently going forward. A member of staff said, "If a client has a new medication it is put on our system with instructions on how to administer and dosage, so I feel confident in administering medication."