This focused inspection of Sipi Care Agency Ltd found that the provider had successfully addressed previous breaches of Regulation 17 (Good governance), with improvements to care planning, quality auditing, and complaints handling lifting the overall rating from Requires Improvement to Good. People and relatives reported personalised, responsive care and a supportive, approachable management team.
Concerns (1)
minorConsent / capacity: “one person's care plan did not clearly record if they had agreed to their care arrangements or a relative had agreed on their behalf”
Strengths
· Care plans were personalised and responsive to people's needs, with previous shortfalls addressed since last inspection
· Complaints handling systems were in place and people knew how to raise concerns; staff felt listened to
· Provider conducted unannounced spot-checks on care staff in people's homes to assess performance
· Positive open culture with approachable registered manager available 7 days a week
· Provider engaged people and relatives through periodic calls and bi-annual questionnaires
Quality-Statement breakdown (8)
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
Sipi Care Agency Ltd was rated Requires Improvement across all five key questions at its January 2019 inspection, with five regulatory breaches identified covering safe care and treatment, consent, person-centred care, staffing, and good governance. While staff were individually caring and recruitment and infection control processes were sound, significant failings in medicines management, risk assessment, MCA compliance, staff training, and care plan quality posed risks to people's safety and wellbeing.
Concerns (9)
criticalMedication management: “Care plans and medicines administration records (MARs) did not provide a clear record of the medicines that people required or received and the support they needed with their medicines.”
criticalCare planning: “Risk management plans did not always clearly identify risks to people's safety and wellbeing or provide care staff with the information to enable them to reasonably mitigate these risks.”
criticalConsent / capacity: “We did not see a mental capacity assessment to confirm the person did not have the capacity to make specific decisions about their care, nor did we see evidence of a Lasting Power of Attorney.”
criticalPerson-centred care: “People did not have up to date care plans that were personalised to fully reflect their physical, mental, emotional and social needs.”
criticalGovernance: “The assurance processes for ensuring the proper and safe use of medicines was not effective as it had not identified and corrected the inappropriate recording of medicines support.”
moderateStaff training: “Some staff were over-due training sessions...including training in communication and record keeping, confidentiality, first aid and infection control.”
moderateStaff competency: “Staff we spoke with could not give us accurate information about understanding and working within the framework of the MCA.”
moderateRecord keeping: “One person's MARs for the eight weeks prior to our inspection had only been ticked instead of initialled by visiting care staff.”
minorEnd-of-life care: “Care plans did not contain any information around people's wishes, views and thoughts about end of life care as this had not been considered as part of the care planning process.”
Strengths
· Safe staff recruitment procedures were in place and being followed.
· No recorded missed care visits in the last year; staff punctual and given enough travel time between visits.
· Staff individually treated people with kindness, compassion and respect.
· People reported continuity of care from the same carers, building trust.
· Complaints were handled in a timely and appropriate manner.
Quality-Statement breakdown (20)
safe: Medicines management and recordingRequires improvement
safe: Risk assessment and management planningRequires improvement
This focused inspection of Sipi Care Agency Ltd found the service had remedied the previous recruitment breach and was rated Good for safety, but governance remained at Requires Improvement due to limited progress in implementing quality monitoring systems. Further improvements were needed to enable independent service user feedback and to ensure internal audits identified recording issues.
Concerns (3)
moderateGovernance: “We did not see evidence that the registered manager had enabled people to give their views independently, supported by an advocate or family member or evidence of other checks and audits”
moderateRecord keeping: “these checks did not pick up some issues the provider needed to address. This included the need to improve the recording of the support care workers gave people with their prescribed medicines”
minorMedication management: “in all three records care workers recorded they 'gave' people their medicines”
Strengths
· Provider took action to improve staff recruitment, ensuring all files included application forms, two references, employment history, interview records, and DBS checks.
· Safeguarding adults policy reviewed in February 2017 with clear guidance for care workers on identifying and reporting abuse.
· Risk assessments completed prior to care commencement, with clear guidance to care workers on mitigating identified risks.
· Registered manager proactively responded to people's concerns, including liaising with GPs, local authorities, and arranging additional support.
· Regular staff team meetings held throughout 2017 covering care updates, training, and policy reminders.
Sipi Care Agency Ltd retained an overall 'Requires Improvement' rating at this March 2020 inspection, with Safe, Effective and Caring all improving to Good but Responsive and Well-Led remaining unchanged due to ongoing breaches of Regulation 9 (person-centred care) and Regulation 17 (good governance). Key shortfalls included care plans not updated to reflect current needs, communication and sensory impairment information missing from records, and quality assurance systems failing to identify these issues consistently.
Concerns (5)
criticalGovernance: “quality assurance systems had not identified and addressed that some people's care plans had not been updated...This demonstrated a breach of Regulation 17”
moderateCare planning: “some care plans had not been reviewed to ensure they were up to date and reflected people's care...one person's care plans had not been updated for over a year”
moderateCommunication with families: “some did not always identify people's communication or sensory impairment needs...one person used a hearing aid, but this was not recorded in their care plan”
minorRecord keeping: “staff did not clearly record their weekly support for person to access their local community”
minorEnd-of-life care: “some plans did not record the provider had discussed end of life care preferences with a person”
Strengths
· Risk assessments robustly completed, with risk management plans covering health conditions such as epilepsy and diabetes
· Medicines management improved; MAR audits conducted and staff competency assessed
· Consistent care worker allocation providing continuity; people reported comfort with familiar staff
· Staff received comprehensive training including MCA awareness, safeguarding, infection control and food nutrition
· People and relatives spoke highly of staff kindness, dignity, and respect
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
Sipi Care Agency Ltd received an overall rating of Requires Improvement at its first rated inspection, with breaches of Regulation 17 (good governance) and Regulation 19 (fit and proper persons employed) due to ineffective recruitment procedures and quality monitoring systems. The service demonstrated genuine strengths in staff training, medicines management, safeguarding awareness, and delivering caring, respectful support to its 11 service users.
Concerns (5)
criticalStaffing levels: “Three of the five staff files we checked included only one reference.”
criticalGovernance: “The provider had systems to monitor the quality of the service...but these were not always effective.”
criticalSafeguarding: “Another record included a photocopy of a DBS certificate from another care agency...the provider had failed to identify and follow this up with the care worker.”
moderateRecord keeping: “Two of the three records we saw were not person-centred, they referred to people as 'the client' rather than their preferred name.”
minorCare planning: “Other care plans consisted only of a list of tasks for care workers to complete on each visit and did not provide care workers with information about how the person preferred to be supported.”
Strengths
· People told us they felt safe with their care workers and described them as kind, caring and professional.
· Care workers received appropriate training including safeguarding, MCA, moving and handling, medicines awareness and infection control.
· The provider worked within the principles of the Mental Capacity Act 2005 to support people to make their own decisions.
· People's religious, cultural and communication needs were recorded and understood by care workers.
· There was an open culture; people, relatives and care workers felt able to approach the management team.
Quality-Statement breakdown (20)
safe: Recruitment proceduresRequires improvement
safe: SafeguardingGood
safe: Medicines managementGood
safe: Staffing levelsGood
safe: Risk assessmentGood
effective: Mental Capacity Act complianceGood
effective: Staff training and inductionGood
effective: Supervision and appraisalGood
effective: Induction and supervision of new staffGood
effective: Nutritional and hydration supportGood
caring: Kindness, compassion and respect from staffGood
caring: Person-centred care planning supporting individual involvementRequires improvement
caring: Privacy and dignityGood
responsive: Person-centred and up-to-date care plansRequires improvement
responsive: Flexibility and responsiveness to individual needsGood
responsive: End of life care planningRequires improvement