Blue Sapphire Care Limited

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.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained 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 provider was in breach of the legal regulation in relation to good governance.

This service scored 62 (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, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There were examples of a positive and inclusive culture within the service. Regular team meetings and staff surveys were undertaken, and staff spoke positively about leaders. Staff told us they felt listened to, supported and valued in their roles. One staff member said, "Blue Sapphire is an excellent care agency, we are like a family, the care we give is excellent."

Communication concerns raised through staff surveys were discussed at team meetings, demonstrating leaders sought feedback from staff and encouraged engagement.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff spoke positively about the leadership team and described managers as approachable and supportive. One staff member said, "The senior staff are very approachable and take the time to listen and take appropriate steps to resolve any problems straight away." Leaders were visible within the service and encouraged staff to raise issues and seek support when needed.

External professionals also provided positive feedback about leaders. People told us they knew who the manager was and were able to contact them if needed. One person said, "They're good at communicating, they answer emails and phone calls promptly."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy in place and encouraged staff to speak up where needed. Staff told us they felt comfortable raising concerns and were confident they would be listened to. Team meetings and staff surveys provided additional opportunities for staff to share their views and experiences. A staff member said, "I feel comfortable raising concerns or asking questions when needed, and management is approachable and responsive."

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. We did not identify any concerns relating to workforce equality, diversity and inclusion. Staff told us they felt treated fairly and respectfully.

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 had some quality assurance processes in place; however, these were not always effective in identifying concerns, providing robust oversight or driving improvement. Some audit activity was being completed, but there was limited evidence of analysis or evaluation of findings.

For example, the provider's electronic medication system contained a function to audit medicines management. During the inspection, we found this function was not operating effectively and the provider had not introduced an alternative process to monitor medicines. This meant leaders did not have effective oversight of medicines management. Since the inspection, the provider has submitted evidence demonstrating that medicine audits are now being completed.

Care plans had recently been audited and reviewed by leaders. However, records we examined contained missing sections and lacked sufficiently detailed risk assessments to support staff to manage risks and keep people safe. Despite this, records had been signed off as complete, which demonstrated shortcomings in the effectiveness of governance and oversight processes.

We also found examples of conflicting information within care records, which could place people at risk of harm. For example, one person's care records stated they had swallowing difficulties and could eat soft foods, while elsewhere it was recorded that staff did not assist them with eating. There was no clear guidance for staff on how to safely support the person with eating and drinking. This meant staff may not have had the information they needed to provide safe and consistent care, increasing the risk of accidental harm, including choking. The provider's oversight systems had not identified or addressed these inconsistencies, which further demonstrated that governance arrangements were not always effective in ensuring records were accurate, complete and reflective of people's needs.

In addition, there were no safeguarding logs in place to support leaders in monitoring safeguarding concerns, identifying themes or tracking actions taken. While leaders were visible and engaged, governance systems were not sufficiently robust to provide assurance that risks, quality and safety were being effectively monitored and improved.

However, staff demonstrated a good understanding of the people they supported, and there was no evidence that people had come to harm as a result of these concerns.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

The provider worked effectively with external agencies and professionals. Feedback from professionals was positive and demonstrated leaders maintained constructive working relationships with partner organisations. Learning was not always identified and therefore could not be shared with partners. One professional told us, "In my experience [Provider] have an excellent management team in place – always professional and proactive." This helped support joined-up care and positive outcomes for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was limited evidence of analysis, evaluation of findings or lessons learned. We saw feedback from staff had been reviewed and themes identified. For example, communication concerns raised through staff surveys were discussed during team meetings. However, records did not clearly demonstrate what actions had been taken or what outcomes had been achieved as a result.This meant the provider could not consistently demonstrate how learning from audits, staff feedback and service performance was used to drive and sustain improvement.