9 September 2020
During an inspection looking at part of the service
Sycamore House is registered for 42 beds and provides personal care and accommodation for older people. On the day of our visit 37 people were using the service. This included ten people living in Kenyon Lodge, this is a separate unit within Sycamore House for people living with advanced dementia.
People’s experience of using this service and what we found
Systems and processes had improved since the last inspection, but were not fully effective or embedded. We identified ineffective recording of people’s individual care needs. Information recorded was not consistent and therefore confusing to staff. People’s care plans and risk assessments did not consistently reflect people’s current needs.
Inconsistent management had impacted on the development of the service and staff felt that they were not always listened too or supported.
Plans were not always in place to ensure people’s safety. Some personal emergency evacuation plans were not readily available for staff in the event people needed to be evacuated.
Some concerns were raised about staffing levels. The management team were requested to follow up on the concerns received. Safe recruitment processes were used to ensure only staff suitable for their role were employed at the service.
People received their prescribed medicines safely. Some shortfalls were identified in the management of medicines, but this had a low impact on people.
Risks associated with people’s individual care needs had been assessed and were monitored. Improvements had been made to ensure people’s hydration needs were met.
Safeguarding concerns were reported to the local authority and CQC. The provider had introduced a more robust system of identifying and analysing incidents.
Infection prevention and control best practice guidance had been implemented by the provider and was being followed by staff. Covid 19 guidance was available to staff and people. Staff were observed wearing personal protective equipment correctly.
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 Requires Improvement (Published on 12 April 2019) and there were two breaches of regulations. The provider completed an action plan after the last inspection, to show what they would do, and by when, to improve. At this inspection, enough improvement had been made to meet the regulation 12 breach, further work was required to meet the regulation 17 breach.
The overall rating for this focused inspection remains as Requires Improvement.
Why we Inspected
We received concerns in relation to the management of the service and care and treatment of people. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only. We also followed up on previous breaches.
We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.
We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.
Enforcement
We have identified a breach in regulation in relation to the governance of the service. 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 from 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.