Sevacare Birmingham Central is a domiciliary care provider supporting people in their own homes. Not everyone using Sevacare Birmingham Central receives a regulated activity; CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do, we also take into account any wider social care provided. At the time of the inspection the service was supporting 215 people. This assessment was completed on 19 February 2024. We visited the office location on 04 March 2024 to see the registered manager, office staff and care staff; and to review care records and policies and procedures. On 05 March two experts by experience made telephone calls to people who used the service and their relatives. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. We spoke with 8 people, 14 relatives. We received feedback from the local authority and professionals linked to the service. We looked at the following quality statements; 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; person-centred care, care provision, integration and continuity, providing information, listening to and involving people, equity in access, equity in experiences and outcomes, freedom to speak up, workforce equality, diversity and inclusion, partnerships and communities.
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Sevacare Birmingham Central was rated Good overall at its February 2017 inspection, with staff providing safe, caring and responsive care to 253 people in their own homes. The Well-Led domain required improvement due to ineffective auditing that failed to identify gaps in risk documentation, MCA consent recording, and competency checks for complex procedures.
Concerns (7)
moderateCare planning: “some moving and handling risk assessments did not refer to any risks associated with using the hoist and did not specify how to safely move the person”
moderateGovernance: “some of the audits had failed to identify and address the shortfalls we had identified. People's risks were not consistently well-managed”
moderateConsent / capacity: “Some care documents we viewed had 'consent forms'...signed for by a relative...There was no evidence to support that the relative had the appropriate authority to sign”
moderateIncident learning: “care manager informed us of future plans to ensure they had systems in place to demonstrate an oversight of incidents, late calls and missed calls”
moderateStaff competency: “competency checks had not been undertaken to ensure staff undertook complex medical procedures safely”
minorRecord keeping: “audits in place to check people's daily communication notes had not identified that on occasions words were used to describe specific tasks which were not dignified”
minorMissed or late visits: “They [the staff] can be late. For example, this morning they should have come at 10.30am and it was 11.30am. They are often at least 30 minutes late.”
Strengths
· People felt safe with staff and expressed high levels of trust in the staff supporting them.
· Medicines management was safe, with a medicines champion undertaking audits and staff trained in medicines administration.
· Staff demonstrated good knowledge of individual people's health needs and used specialist equipment safely.
· People were supported by consistent staff teams; no agency staff were used.
· Staff received regular training, including specialist training (e.g. PEG feeding), and worked through a recognised induction including the Care Certificate.
Quality-Statement breakdown (18)
safe: Safeguarding people from abuseGood
safe: Risk assessment and managementRequires improvement
safe: Medicines managementGood
safe: Staffing and recruitmentGood
effective: Staff training and competencyGood
effective: Consent and Mental Capacity Act complianceRequires improvement
Sevacare Birmingham Central was rated Requires Improvement overall at this March 2016 inspection, with safe and well-led domains falling short due to persistent late and missed calls and ineffective systems for monitoring incidents and identifying trends. Strengths included safe medicines management, good safeguarding practice, positive staff–person relationships, and responsive complaints handling.
Concerns (4)
moderateMissed or late visits: “"They [the staff] are always late, and especially weekends." and "Staff do run late frequently."”
moderateIncident learning: “there were no effective systems in place to use the information gained to analyse trends which could prevent the likelihood of negative experiences for people recurring.”
moderateGovernance: “systems in place for recording and monitoring late calls required development to ensure that people's needs had been met as planned”
moderateConsent / capacity: “people's mental capacity to consent to care had not always been assessed and reflected in their care plans in line with the MCA guidelines.”
Strengths
· People felt safe with staff and staff demonstrated good safeguarding knowledge and procedures.
· Medicines management was effective and safe, with regular competency assessments of staff.
· Staff received a range of training including specialist training, induction, and the Care Certificate.
· Staff received regular supervision and spot checks to ensure competency.
· Care plans reflected individual preferences and people were involved in care planning.
Quality-Statement breakdown (14)
safe: Staffing and call reliabilityRequires improvement
Sevacare Birmingham Central, supporting 252 people with personal care, improved from its October 2018 inspection but retained an overall rating of Requires Improvement, with Effective and Caring now rated Good. Persistent inconsistency in call visit timings, gaps in staff spot-check records, and incomplete complaint and end-of-life records continued to undermine safety, responsiveness and governance.
Concerns (6)
moderateMissed or late visits: “eight calls were not at the scheduled times on staff rota's. However, all calls were undertaken.”
moderateMissed or late visits: “eleven people told us that the timings of their calls could be better. One person said, "The times are not consistent it is all different times."”
moderateGovernance: “the provider's quality audit system for staff supervision was not effective...three staff that had not received spot checks for four years and two staff had not received spot checks for two years.”
moderateGovernance: “issues around timings of calls had not been acted on by the registered manager and it was not clear if these issues had been highlighted by audits.”
minorComplaints handling: “some parts of the complaint forms had not consistently been completed to demonstrate that lessons had been learned.”
minorEnd-of-life care: “there was little evidence from records we sampled that people had been asked for their preferences regarding their end of life wishes.”
Strengths
· No missed calls reported by people at this inspection, an improvement from the previous inspection.
· People felt safe with staff, with all spoken with confirming staff were caring, kind and respectful.
· Medicine administration records (MARs) were well maintained with no gaps and staff competency in medicines had been assessed.
· Care plans were person-centred, detailed and contained clear guidance on individual needs, preferences and cultural requirements.
· Staff demonstrated good understanding of the Mental Capacity Act and obtained consent before providing care.
Quality-Statement breakdown (23)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
caring: Kindness, dignity and respectGood
caring: Involvement in care decisionsGood
caring: Promoting independenceGood
responsive: Person-centred care planningGood
responsive: Responding to people's needs and requestsGood
responsive: Complaints handlingGood
responsive: Cultural and diversity responsivenessGood
well-led: Quality assurance and auditRequires improvement
well-led: Leadership and management cultureGood
well-led: Staff engagement and organisational learningGood
caring: Person-centred approach
Good
responsive: Care planning and personalisationGood
responsive: Complaints handlingGood
well-led: Quality assurance and governanceRequires improvement
well-led: Incident and accident analysisRequires improvement
well-led: Leadership and cultureGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Planning and promoting person-centred, high-quality care and support with openness; and how the provider understands and acts on their duty of candour responsibilityGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
well-led: Continuous learning and improving careRequires improvement