Sugarman Health and Wellbeing - Watford

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 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 service was in breach of legal regulation in relation to staff competency, medicines management and managing risk.

This service scored 50 (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 not always ensured staff learned from incidents. Incidents were recorded on an events tracker and investigated by the registered manager and service delivery manager. We reviewed some incident reports and found these did not always include actions and learning. During discussion with managers, we found more was done in response to incidents than was recorded. Feedback from staff was mixed; a staff member said, “Information following incidents, complaints, or safeguarding concerns is shared.” We were also told, “Managers inform us all the time about changes and incidents and complaints or any other safeguarding issues.”However, no staff we spoke with were able to give a specific example of a recent incident and a staff member told us, “This is an area that needs to be improved. It appears to be a disconnect with the package and the office at times and there is not a named or known supervisor or team leader to raise concerns to. I feel they could improve this; their follow up is poor.” Therefore, we were not assured lessons were always learnt to continually identify and embed good practice.

The provider worked with other professionals. We saw records in people’s files included information to support management of healthcare needs people had and attendance at meetings. A professional told us about a person who transferred to the service and said, “The discharge was relatively smooth, the patient had complex physical and emotional needs, but I am informed that [they are] doing well.”

Staff had limited understanding of safeguarding and struggled to give examples of what they would report. A member of staff described safeguarding as, “Making sure clients are ok, they are being cared for.” They were unable to tell us of any raised and what learning resulted from them.

The registered manager investigated safeguarding concerns and took action in response.

At the time of our inspection, they told us there were no open safeguarding concerns.

The provider had a safeguarding policy; this did not include contact details for the various local authorities who commissioned care with the service. This meant staff may not have the details needed to make a referral to the appropriate team.

People’s relatives gave mixed feedback; there had been safety incidents which had led some families to question the competence of staff. However, most family members we spoke with felt staff provided safe care the majority of the time. A relative said, “I’m confident that the [staff] we’ve got now, keep my [relative] safe.”

The provider had not ensured staff managed risks to people well. Staff did not complete care records consistently; therefore, we were not assured care was provided in accordance with their care plans. For example, a person’s care plan stated their inner cannula should be changed and their oxygen saturation level checked every 4 hours. We reviewed daily logs and found delays in changing the cannula without explanation each day. This meant they were at risk of airway obstruction and increased risk of infection. Their oxygen saturation levels were not recorded; only 1 entry in a 10-day period provided an explanation for this not being done. This meant there was a risk signs of deterioration in their health condition may not be identified in a timely manner and placed them at risk of harm.After our inspection, the registered manager told us following a meeting with the person’s relative and discussion with the clinical team at the service, it was agreed the oxygen saturation level observations could be reduced. However, the person’s records had not been updated to reflect this.

People’s records did not always contain consistent information. We found gaps and discrepancies in care plans and risk assessments. For example, a person’s choking risk assessment stated they had sepsis in the past; their care plan had a template for sepsis which had not been completed. This meant there was no guidance for staff to ensure they recognised the signs.Following our inspection, the registered manager shared a fact sheet about signs of sepsis and told us this was in their care plan.

Staff assessed people’s homes for risks in relation to the environment. We saw this included information about utilities, trip hazards and fire evacuation plans.

The provider had not made sure there were always enough qualified, skilled and experienced staff to provide safe care. Care staff completed a 2-day webinar training course in clinical needs, followed by shadowing experienced staff in people’s homes. Shadowing continued until they were signed off as competent by a nurse prior to working alone. Whilst we saw competency assessments were documented following initial training, we saw no evidence of ongoing competency assessments. This meant we were not assured staff were kept up to date with changes in clinical practice. The registered manager advised staff were continually assessed by nurses through observations at spot checks and supervisions. However, the frequency of this was unclear and there were no prompts on the spot check or supervision forms to include observation of clinical tasks.Following our inspection, the registered manager advised they had implemented a formal annual competency review system.

People’s relatives described concerns about the quality of the training staff received. A relative said, “The training is my main concern – so much is done on the internet rather than face to face and for the care that my [relative] needs, that’s often not enough…We need to know that staff know what to do when my [relative] is unwell, and we don’t always feel confident that this is the case.” Another relative said, “The previous care agency trained their staff to a very high standard, but I can’t say that about Sugarman.” We were also told, “Some new carers have started recently, and they tend to send them in without a chance to shadow the more experienced confident staff and that’s not helpful.”

Staff feedback suggested they did not feel supported in their roles, but most felt they had enough training. However, 1 member of staff told us, “We are working in complex care and sometimes when you are working alongside your colleagues you can see they are not trained.” Therefore, we were not assured the process to ensure staff were competent was effective.

The provider assessed and managed the risk of infection. Staff used the appropriate personal protective equipment when providing care. A staff member said, “We use gloves, nose mask, aprons and foot covers. We contact the office to order it, and it is kept in the person’s house.”

The provider had an infection control policy. Compliance with this was monitored via on site supervisions and staff spot checks.

The provider did not always make sure medicines were managed safely. Staff did not document people’s medicines administration well. We reviewed people’s records and found Medication Administration Record (MAR) charts were not always signed or had numerous entries where medicines were not administered without explanation or action taken.

Where PRN medicines, which are those administered as and when required were prescribed there were not always protocols to guide staff when to administer them.

Staff audits of MAR charts were not effective. We found 1 stated omissions/errors had been identified but the issues we found were not recorded and remained unexplained. In another example they noted the need for gaps to be explained but there was nothing to suggest the reasons were followed up with staff; there seemed to be an assumption it was just a missing signature, but it could have meant the medicine had not been administered at all. This meant there was a risk people were not receiving their medicines as required.