The Care Quality Commission (CQC) has dropped the rating of Sambhana Care Ltd from requires improvement to inadequate and placed it in special measures, following an inspection in January.
Sambhana Care Ltd is a domiciliary care agency providing personal care to adults living in their own homes. The service was providing personal care to 39 people at the time of this inspection.
This inspection was carried out to follow up on two warning notices CQC issued the service at its last inspection in July 2024, due to concerns around people’s safety and the management of the service. This inspection found these issues hadn’t been fixed and some issues had gotten worse.
CQC has dropped the service’s overall rating from requires improvement to inadequate, as well as for safe. CQC has dropped the service’s ratings for effective, caring, and responsive from good to inadequate. CQC has again rated well-led as inadequate.
CQC has also begun the process of taking regulatory action to address these concerns, which Sambhana Care Ltd has the right to appeal.
Serena Coleman, CQC deputy director of operations in the south, said:
“When we inspected Sambhana Care Ltd, we were deeply concerned to find a closed culture, in which leaders were actively dishonest and encouraged staff to do the same, which didn’t protect people from harm or improve their care.
“We found that when people had experienced harm or made allegations of abuse, leaders hadn’t investigated these incidents or reported them to outside organisations such as CQC and the local authority as legally required, and in one case had pressured staff to be dishonest about what happened. This is how a closed culture developed.
“Staff told inspectors they’d been asked to change records about an incident in which a person was left without care for three days. This was because leaders hadn’t told staff they were home from hospital. This is unacceptable.
“Staff told us they were distraught at their actions, but felt they had no choice because they could lose their jobs or sponsorships to work in the UK. I want to praise those staff who were brave enough to come forward, as speaking up in these circumstances is not easy, but is important and helps to give CQC a true picture of people’s care.
“When inspectors told leaders to raise these incidents, the information they provided was still inaccurate and missing details. Because they hadn’t reported or investigated these incidents when they happened, leaders had missed opportunities to learn and protect people from repeated mistakes.
“People’s quality of care had dropped since our last inspection and people weren’t always cared for in person-centred ways to meet their individual needs. Staff didn’t always treat people with kindness or respect their consent, and leaders had made decisions which could violate people’s rights.
“Leaders had stopped one person from having visitors to their home, though we saw no evidence they’d been unhappy with this, replacing it with a weekly trip to their religious meeting place. They hadn’t assessed this person’s mental capacity when making this decision but decided this is what they’d want, which could violate their rights. This decision put them at higher risk of isolation, depression, and accidents.
“During this inspection, leaders continued to be defensive about their actions. They’d acted without consideration for the people in their care, and their response to this showed they had little regard for people’s wellbeing.
“We’ve told leaders where immediate improvements are needed and have begun taking regulatory action which Sambhana Care Ltd have the right to appeal. We will continue to closely monitor this service to ensure people are kept safe while the necessary improvements are made.”
Inspectors also found:
- The service hadn’t always given people’s relatives accurate information about their health or care. When things had gone wrong, they’d given people’s relatives information in a way that reflected positively on the service.
- While some people and their relatives praised the service, some people who didn’t have someone to speak on their behalf hadn’t always received the safe and good quality care they deserve.
- Leaders didn’t have oversight of people’s care and weren’t learning from incidents to keep people safe. One person had fallen three times while home alone but leaders hadn’t investigated or acted to prevent this risk in future.
- Leaders didn’t make sure there were enough staff who had been recruited appropriately or given the training and supervision to make sure they could support people safely.
- People’s care records weren’t always accurate, detailed or personalised to support people’s individual needs or risks. For example, a care plan for a blind person advised staff to stand in front of people with sensory needs, to help them lip read. They also lacked information for staff on how to recognise when people were unwell or when to get people medical help
- The service didn’t always give people information in ways they could understand.
- People had been put at risk of discomfort because leaders didn’t make sure staff knew when people’s needs had changed.
- People’s medicines weren’t always managed safely.
- The service didn’t work well with other organisations to meet people’s needs. For one person supported by a different care agency overnight, leaders didn’t know which agency was preparing their breakfast or if they were getting it.
- Staff didn’t always know how to support people’s religious and cultural needs, despite the service supporting people from different ethnic backgrounds, including many Punjabi people. One person told inspectors not all staff knew how to make a turban, which they needed assistance with.