Saffron Court

Updated 8 February 2022

The inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Adjuvo (Midlands) Support for Living Ltd, Saffron Court is a domiciliary care agency. It provides personal care to people living in flats within Saffron Court. It provides a service to adults living with a range of health and care and support needs including people living with a learning disability and or mental health needs.

Notice of inspection

This was an unannounced inspection.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We reviewed information we had received about the service since the last inspection. We used all of this information to plan our inspection.

During the inspection

We spoke with one person about their experience of the care and support they received. We spoke with the service manager, a care worker, an agency worker and the administrator. We reviewed a range of records. This included in part, two people's care records. We looked at one staff file in relation to recruitment. We looked at a variety of records relating to the management of the service, including incident records. We reviewed infection prevention and control practice.

After the inspection

We continued to seek clarification from the provider to validate evidence found. This included but was not limited to the provider's training data, policies, procedures, an improvement plan. We also spoke with two relatives for their feedback about the service and we spoke with the registered manager.

Updated 8 February 2022

Adjuvo (Midlands) Support for Living Ltd., Saffron Court is a domiciliary care agency. The service provides care and support to people living in ‘extra care’ housing. Extra care housing is purpose built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupants’ own home. The extra care housing complex was known as Saffron Court and was made up of individual flats.

Not everyone living at Saffron Court receives a service from the domiciliary care service. People receiving care and housing are provided under separate contractual agreements. The Care Quality Commission (CQC) does not regulate the premises. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of the inspection, five people were receiving the regulated activity of Personal Care.

People’s experience of using this service and what we found

Risks associated with people’s individual care and support needs had not been sufficiently assessed to ensure people’s safety. Risk assessments had not been regularly reviewed or amended when people’s needs changed.

The provider had an incident management system used to review, monitor and manage incidents that occurred. This included oversight and analysis to enable learning to reduce further risks. However, this was not fully effective.

There was a high use of agency staff to cover staff vacancies. The provider did not have details of agency staff to check their identity, and to assure themselves staff had undergone safe recruitment checks and were sufficiently trained. The provider had failed to provide staff with training and support to meet some people’s specific health, care, and support needs.

The provider’s governance systems and processes used to assess, monitor, and mitigate risks and to develop and make improvements were not fully effective or robust.

Infection prevention and control practice did not fully reflect best practice guidance. This included the monitoring of COVID-19 testing, assessment and risk management for people at high risk, how used personal protective equipment (PPE) was disposed of and was not monitored.

The provider’s safeguarding policy did not reflect the local multi-agency safeguarding procedures. However, staff had details of how to make a safeguarding referral. When safeguarding incidents, concerns or allegations had occurred these had been acted upon and reported correctly to external agencies including CQC.

Relatives who gave feedback, raised concerns about the high use of agency staff and their concern of the impact on continuity and consistency of care. However, they spoke highly of the permanent staff employed.

A person who used the service was positive about the care and support they received. They confirmed staff mostly arrived on time and stayed for the duration of the pre-planned care visit.

At the time of the inspection, people receiving personal care and support managed their prescribed medicines independently. However, the provider’s medicines systems and processes reflected best practice guidance.

The new registered manager and service manager who had day to day responsibility, were aware of improvements required and showed commitment and determination to develop the service. The provider was also making changes within the organisation to further develop and improve.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 22 May 2019).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about infection prevention and control and staff deployment at the service. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with risk management, staff deployment, training and the provider’s governance systems, so we widened the scope of the inspection to become a focused inspection which included the key questions of Safe and Well-led.

Please see the Safe and Well-led sections of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Saffron Court on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risk management, staffing, including training, and the provider’s governance systems and processes used to monitor quality and safety and drive improvements.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.