Sagecare (Lincoln) was rated Requires Improvement overall following a focussed inspection in November 2022, with confirmed breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) persisting from the previous inspection. Key failures included unsafe medicines management, poor risk documentation, chronic staffing deployment problems causing missed or shortened care calls, and ineffective governance systems unable to drive improvement across four consecutive inspections.
Concerns (13)
criticalMedication management: “People did not have protocols in place for 'as needed' (PRN) medicines and this was not in line with best practice.”
criticalMedication management: “Staff had recorded this patch had been changed on medicine administration records (MARs), but then recorded in care notes that this patch would be changed at a later care call.”
criticalIncident learning: “Despite this known risk, there was no information to inform staff to encourage this person to use their lap belt to reduce the risk of re-occurrence.”
criticalStaffing levels: “'[Sagecare] say to me We've got nobody to come at a weekend... [my other support] can't do personal care or my pills and that's what I need.'”
criticalGovernance: “Audits delegated by the registered manager, such as care audits and medicines reviews, failed to identify issues with care records.”
criticalGovernance: “Provider systems were ineffective in driving improvement to enable them to achieve a good rating. This was the fourth consecutive inspection where the service was rated requires improvement.”
moderateStaffing levels: “[Sagecare] are changing 40-minute care calls into 20-minute care calls or no care call at all. The poor carer doesn't know what's going on.”
moderateRecord keeping: “People's care plans and risk assessments were not updated following changes to people's care and contained outdated information about risks to people.”
moderateCare planning: “Staff failed to document relevant information to help manage risk... staff had recorded on several occasions that this had been completed by others, with no further information.”
moderatePerson-centred care: “Issues with staffing pressures and deployment impacted on the service's ability to provide person-centred care.”
minorCommunication with families: “I don't mind if the time varies, but they need to tell me. Mostly they don't, and I have to ring up to find out.”
minorInfection control: “People told us some staff did not always wear appropriate person protective equipment (PPE).”
minorSafeguarding: “Some staff were not always aware of provider whistleblowing procedures.”
Strengths
· People and relatives told us they felt safe using the service; one person said 'I do feel safe with them, they know what they are doing.'
· Some evidence of lessons learned following incidents such as medicine errors.
· A time-critical medicines audit supported people to receive medicines at the right time of day.
· The provider worked closely with other agencies including district nurses, families, day centres and the local authority.
· The registered manager contacted people and relatives to apologise when things went wrong.
Quality-Statement breakdown (6)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candour; Working in partnership with othersRequires improvement