Date of inspection: 2 October 2025 – 4 December 2025. Sage Care (Southwark) is a care at home service providing to support to older people, people with physical disability and sensory impairment, younger adults, people with mental health, and people with learning disabilities or autistic spectrum disorder. At the time of the inspection there were 225 people using the service. At this inspection, the service has been rated requires improvement. We assessed the service against ‘right support, right care, right culture guidance to make sure judgements whether the provider guaranteed people with a learning disability or autistic people, respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. Pre-employment checks were completed to ensure recruitment was safe. These checks included Disclosure and Barring (DBS) and Right to work in the UK (RTW) checks. Electronic Call Monitoring Data (ECM) highlighted there was issues with high levels of late visits to people. People had care plans and risk assessments in place. Some care plans were not person centred and did not have enough information to fully inform staff how to support people with complex care needs. Some care plans had generic information for staff to follow in relation to evacuation plans from people’s home in the case of an emergency. Information in these plans did not align to people’s mobility or support care needs. We raised this with the management team and plans, and risk assessments were amended. The service had governance and audit systems in place, but these did not identify or address issues we found during the inspection. The service had a range of policies and procedures in place for staff to follow and work towards keeping people safe. The service was in breach of legal regulations in relation to safe care and treatment and good governance. We have asked the provider for an action plan in response to the concerns found at this inspection.
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Sagecare (Southwark) was rated Requires Improvement overall following a December 2022 inspection, with regulatory breaches identified for failing to comply with the Mental Capacity Act (Regulation 11) and for inadequate governance systems (Regulation 17). Key concerns included unreliable care call timekeeping, generic non-personalised care plans, absence of a registered manager, and a culture of poor internal communication and unresolved complaints.
Concerns (8)
criticalConsent / capacity: “The provider was not working within the principles of the MCA. Staff had not always completed MCA assessments for people in line with their policy.”
criticalGovernance: “The provider was not always operating effective systems and processes to assess, monitor and improve the quality and safety of the service.”
moderateMissed or late visits: “Our analysis highlighted timekeeping issues, including examples where care workers were not logging calls correctly, being logged into two locations simultaneously and issues with care workers turning up late.”
moderateCare planning: “We found the same information was recorded for six people which stated that they should have 'A low sugar diet, encourage me to have a sugar free diet'... we were not assured that care plans were personalised.”
moderateComplaints handling: “Within the file there was no record of the correspondence outcome sent to three people which meant we were not always assured people were told the outcome of their complaint.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post... care workers spoke about a culture of favouritism and people felt communication needed to be improved.”
moderateCommunication with families: “People and their relatives felt the office was not well managed due to the attitude of office staff... 'If I ring the office, they are terrible.'”
minorIncident learning: “A complaint had been made earlier in the year about this issue and no learning had taken place.”
Strengths
· Medicines were administered safely using a live electronic system with regular audits and staff competency assessments.
· Robust safeguarding procedures were in place and people told inspectors they felt safe when receiving care.
· Strong recruitment processes in place including full employment history, qualifications, and references.
· People described care workers as kind, caring and respectful of their dignity and privacy.
· Care workers received thorough induction including the Care Certificate, shadowing, and regular supervisions and appraisals.
Quality-Statement breakdown (22)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
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
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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 ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Meeting people's communication needsGood
responsive: End of life care and supportNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
Sagecare (Southwark) received five regulatory breaches across safe care, medicines management, care planning, staffing and governance at its first CQC inspection, with all five key questions rated Requires Improvement. A newly appointed manager had begun addressing systemic failures including incomplete risk assessments, 75% mandatory training compliance, 72 staff lacking supervision records, and a history of late and missed visits, but improvements were not yet embedded at the time of inspection.
Concerns (10)
criticalCare planning: “provider's own analysis indicated there was an 80% compliance with people having a full care plan in place. Care staff were using 'care grid service schedules'...which did not have the necessary level of detail”
criticalMedication management: “medicines were administered late, due to care staff arriving late...previously there was a lack of managerial scrutiny and auditing in relation to medicine practices”
criticalStaff training: “compliance level for mandatory training was 75%...42 did not have any evidence of having completed the TUPE workbook...72 staff did not have evidence of supervision on file”
criticalSupervision / appraisal: “staff did not receive regular one to one support and guidance from their line managers...72 staff did not have evidence of supervision on file”
criticalGovernance: “provider had failed to implement and maintain the use of effectual quality monitoring practices...86 staff had not had a 'spot check' visit by a field care supervisor”
moderateMissed or late visits: “some people had experienced disruptions...due to unforeseen changes to staff they were not advised about in advance, late visits, missed visits and visits that felt rushed”
moderateRecord keeping: “risk assessments had not been undertaken for all people using the service...one care worker informed us they provided personal care for a person with a PEG tube but did not have written information”
moderateComplaints handling: “Not all of these complaints had been resolved within the timescales set...we did not see ongoing evidence of how the former management team used this information to improve the quality”
moderateLeadership: “The service did not have a registered manager. The new manager had been in post for two weeks at the time we commenced the inspection.”
minorConsent / capacity: “current assessment tool...did not have a section for field care supervisors or managerial staff to confirm in writing they had been shown an original LPA document”
Strengths
· Recruitment practices were safely conducted with thorough background checks to ensure staff had suitable experience.
· Care plans contained personalised information about people's life history, interests, and cultural practices to support meaningful relationships.
· Staff demonstrated clear understanding of safeguarding policies and procedures, including how to report concerns.
· People's nutritional needs were satisfactorily met where this formed part of their assessed care package.
· The new manager had developed a detailed action plan identifying shortfalls with clear responsibilities and timescales.
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices: delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access health care services and support
Sagecare (Southwark) improved from Requires Improvement to Good across all inspected key questions, having resolved all prior regulatory breaches relating to risk assessment, medicines management, care planning, staff training and governance. The service demonstrated sustained improvement under a new registered manager, with positive feedback from people, relatives, staff and the local authority.
Strengths
· Significant improvements made since previous 'Requires Improvement' rating, with all prior regulatory breaches resolved
· Comprehensive risk assessments in place, regularly audited and updated to reflect people's current needs
· Safe and reliable medicines administration systems implemented, with MAR audits and staff competency checks
· Staff well-supported with structured induction, Care Certificate, mandatory training and responsive line management during COVID-19
· Person-centred care plans developed with individuals, reviewed regularly and written to reflect wishes, preferences and social interests
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choicesGood
Good
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
caring: Ensuring people are well treated and supported; equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
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 needsGood
well-led: Planning and promoting person-centred, high-quality care and support; duty of candourRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people who use the service, the public and staffRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersRequires improvement
effective: Supporting people to eat and drink enoughGood
effective: Supporting people to live healthier lives and access healthcareGood
effective: Staff working with other agenciesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
responsive: Planning personalised care to meet needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care needsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about roles and regulatory requirements; duty of candourGood
well-led: Engaging and involving people, the public and staffGood
well-led: Continuous learning and improving care; working in partnershipGood