Sentricare Birmingham

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 inadequate. 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 provider was previously in breach of the legal regulation in relation to safe care and treatment. Not enough Improvements were found at this assessment, and the provider remained in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to Safeguarding People from Abuse and Improper Treatment, Fit and Proper Persons Employed, Staffing, and Duty of Candour. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.

Staff consistently described how they would safeguard people, showing a strong understanding of safeguarding procedures and reporting pathways. They also confirmed they would escalate concerns externally when required and knew which external agencies to contact, indicating they were not solely reliant on internal management structures.

There was evidence of accessible and supportive management, which can help strengthen a positive learning culture. Staff expressed confidence that management support was always available.

However, the organisation did not always translate learning and oversight into effective quality assurance. This was particularly evident in the areas of medicines management and governance processes. These weaknesses reduced assurance that learning was consistently embedded through audits and review arrangements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Records reviewed showed the provider had structured care planning systems and review schedules designed to support continuity of care. We found care plans and associated risk assessments were comprehensive. They provided clear task guidance and outlined responsibilities between family members and staff, enabling consistent care delivery and reducing reliance on informal knowledge during staff changes.

Staff knew people and their risks well and told us how they worked with professionals to keep people safe.

At the last inspection we found people were not protected from abuse and improper treatment, notifications of notifiable incidents were not always submitted to the CQC. At this inspection we found improvements had been made.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately with the local authority safeguarding team and made relevant notifications to CQC.

People using the service and their relatives told us they felt safe and were happy with their care. We were told, “[Name of person] feels very safe in their home, the carers know their job, very caring and [name of person] is very close to them, certainly no sign of any form of abuse. No history of falls or accidents.” and “No issues around abuse or safeguarding, very good carers.”

Staff we spoke with knew people and their needs well, had access to safeguarding policies and received safeguarding training. Staff told us they would report any safeguarding concerns immediately. One said, “If I became aware of any concerns, I would inform the management team. I would inform the local authority safeguarding team.”

The provider worked with people and their relatives to manage risk, but their approach was sometimes inconsistent. Several gaps reduced overall assurance about how well risks were understood and consistently managed in practice. For example, although one person’s diabetes management plan identified safe blood sugar parameters and symptoms of hypoglycaemia, it did not clearly specify how staff should monitor blood sugars beyond recognising symptoms. There was also limited evidence of co‑signatories on some risk assessments, reducing confidence that risks had been discussed, understood and agreed with individuals or those representing them.

Additionally, feedback from some relatives indicated that care sometimes felt task‑focused and inconsistent. One relative told us, “The second carer sometimes doesn’t arrive for 20 minutes.” Another relative told us, “They’re doing the basics and even then, we feel we have to watch over them.” We raised these concerns with the registered manager who confirmed they would conduct further reviews with people and their relatives.

However we did find, one person’s choking risk assessment clearly outlined the requirement for soft foods, and there was comprehensive guidance on hoisting, manual handling and pressure area management, including escalation to district nursing when necessary. Care plans also described what people could do independently and what support staff should provide, helping promote a shared understanding of risk management.

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

The provider had processes in place to identify environmental risks within people’s homes. Fire risk assessments were completed and hazards such as the use of paraffin‑based emollients were identified, demonstrating awareness of factors that can increase fire risk. This indicated that environmental risks were being actively considered and recorded.

At the last inspection we found the provider did not ensure staff were safely recruited and there were not enough staff to meet people’s needs. At this inspection we found improvements had been made.

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

We found safe recruitment processes were in place. Recruitment records showed that staff were appointed following appropriate checks, including completion of job applications, verification of employment history, DBS checks and Home Office identity checks. Staff also described a structured onboarding process that included induction, initial training and shadowing. Staff told us their competency was assessed and signed off by management before they worked independently. Systems were in place to ensure staff were suitably prepared.

Staff spoke positively about the registered manager and reported good access to support. Most staff said they had sufficient time to meet people’s care needs. However, some people and their relatives described rushed visits and inconsistent timekeeping. One person told us, “They sometimes come too early.” A relative told us, “They don’t stay the full time.” We raised this with the registered manager, as some people’s experiences did not always align with planned visit durations or expectations. The registered manager confirmed they would conduct additional visits to address any issues.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had effective arrangements in place to assess and manage the risk of infection. Staff were trained in infection prevention and control (IPC) and food hygiene, systems ensured training was kept up to date. People and their relatives told us that staff consistently followed good infection control practices, which helped reduce the risk of infections spreading.

The provider also demonstrated appropriate escalation processes, ensuring any concerns relating to infection risk were identified early and shared promptly with relevant external agencies. This supported coordinated responses to potential outbreaks or emerging risks.

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

Medicines processes did not always provide assurance of safe administration or accurate recording. Although the provider had systems in place to check the accuracy of Medicines Administration Records (MAR) charts and supporting documentation, this was not always effective in practice. Records showed multiple discrepancies, medication pen pictures contained directions that did not match the MAR charts; photographs of medicines were inconsistent with the MAR charts; and staff were signing MARs for medicines that were not present in blister packs. Administration instructions were also not followed consistently, for example, a medicine prescribed for alternate‑day administration was recorded as being given daily.

There were further gaps in key information, such as who was responsible for ordering and collecting medicines and from where. These issues increased the risk of people receiving medicines incorrectly, experiencing omitted doses, or having medicines administered without appropriate oversight.

The evidence also raised concerns about staff understanding of the medicines they were administering, as records indicated that staff were not always aware of what they were signing for. Although training and competency assessments were in place, the discrepancies demonstrate that these arrangements were not sufficiently robust or effective. Audit processes also failed to identify these issues.