Sevacare - Hall Green

Systems to assess, monitor and mitigate risks to people, including risks associated with people's long-term health conditions, were not robust or effective. Staff had not always been provided with clear guidance on how to safely meet people's individual needs and manage risks. Staff did not report incidents in a consistent or timely manner, which meant opportunities to learn from these and reduce risks to people were lost. Where incidents and safeguarding concerns had been reported, lessons had not always been learned or improvements embedded into practice. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People's rights under the Mental Capacity Act 2005 were not always fully supported or understood by staff. Staff had not always received appropriate training relevant to their role. Recruitment procedures were robust and people were supported by adequate numbers of staff. People were supported to take their medicines safely. People were protected from the risk of infections.

The provider’s governance and quality assurance systems were not sufficiently effective to ensure the delivery of good quality care and support. Audits and checks completed had not enabled them to identify and address a number of significant concerns we found during this assessment. These included shortfalls in the assessment and management of risks to people. Learning from investigations into concerns was not consistently identified or shared with staff to drive improvements in people’s care. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff and management were not always clear about their individual roles and responsibilities, including the need for staff to consistently report accidents and incidents. The provider did not always liaise effectively with partners for improvement. This included a lack of clear information and guidance for staff in people’s care plans following hospital discharge. Staff felt well-supported by management and felt confident about speaking up at work.