Sycamore Rise Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in continued breach of legal regulations in relation to risk management, medicines, infection prevention control and staffing.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Risks to people were not always effectively used to learn and improve. For example, analysis of incidents were not always recorded. Therefore, the service could not effectively review information to monitor for themes and trends. For example, we saw an accident and incident audit, but there was no documented evidence analysis had taken place. However, we found the management team were open and transparent and wanted to improve the service. Prior to the assessment concluding, the provider and registered manager sent us information which demonstrated how audits had been changed to allow analysis to take place.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. Information was provided to healthcare professionals to support clinical decision making.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and family members were able to raise concerns with safety. The contact details for the Lancashire Safeguarding Authorities were displayed in the home. People were supported by staff who knew why and how to raise safeguarding concerns and a person who lived at the home commented “I feel safe here. No shouting or anything untoward.” Staff told us they would report concerns to the registered manager, Care Quality Commission and Local Authorities if they had concerns.

The service did not always work well with people to understand and manage risks. Risk assessments relating to the health, safety and welfare of two people using the service were not always updated following incidents occurring. This meant plans were not always in place to support people to manage risks. For example, where people were at risk of falls, risk assessments were not always reviewed promptly to mitigate further risks to the person and to maintain their safety. There was no risk assessment to identify and control the risk of people being accidently locked in their private room, people smoking, or of people being unsupervised in communal areas. We discussed our findings with the registered manager who addressed our concerns prior to the assessment concluding.

The provider did not always detect and control potential risks in the care environment. Checks were carried out on equipment to help ensure they were safe to use, however these were not always documented. For example, sensor mats were checked to ensure they were working but these were not documented. Call bells were checked to ensure people could access them, but this was not documented. There was no audit system in place to check that window restrictors were functioning safely and minimised the risk of falls from height. Prior to the assessment concluding, the registered manager introduced an audit system to check window restrictors were functioning safely and instructed staff to document checks on equipment.

The provider did not always make sure effective employment processes were in place and followed and that there were enough skilled and experienced staff. Staff were not always safely recruited. We looked at three personnel files and found full employment histories were not obtained in two of them. We also found a file did not have a recent photograph as required. The recruitment policy did not instruct a full employment history to be obtained as part of the recruitment policy. These areas of concern were addressed by the registered manager before the assessment concluded.

Staff told us they had effective support and development opportunities. However, we found staff had not always had sufficient training. From 01 July 2022, health and social care providers registered with the Care Quality Commission must ensure that their staff receive training on learning disabilities and autism appropriate to their role. The registered manager and staff told us this training had not been completed. We noted two people at the home lived with specific health conditions, staff and the registered manager told us training relating to the specific conditions had not been completed. Prior to the inspection concluding, the registered manager sent us information which showed that appropriate training was being arranged for staff to complete.

The registered manager used a dependency tool to help assess the number of staff required to support people. Overall, people told us they were satisfied with the response from staff. Two people said they felt more staff were required as they sometimes had to wait for support. We discussed this with the registered manager who told us they would investigate this. Prior to the assessment concluding we were informed the provider had invested in a new call bell system for the service. The registered manager told us the new system allowed them to audit the use of the call bell system and supported the development of effective care plans.

The provider did not always assess or manage the risk of infection. Although we received comments such as “It's very clean and everything is kept clean. They have cleaners and somebody to do the laundry.” And “I think the home is kept clean”, improvements were required to minimise the risk and spread of infection. We found some reusable equipment was not always cleaned in a way that minimised the risk and spread of infection. The infection prevention and control policy instructed staff to clean the reusable equipment in an autoclave. An autoclave is a machine to hygienically clean equipment. We were informed there was no autoclave at the home. We saw one shower tray which was black with what appeared to be staining or mould. The laundry required improvement to ensure the risk and spread of infection was minimised. The infection control audits carried out by staff at the home had not identified the concerns we noted. Prior to the assessment concluding, the registered manager implemented further infection control audits help identify areas that needed improvement.

Staff had access to PPE and we saw this was used appropriately. The registered manager told us there was work being planned to improve the laundry area and bathroom were being refurbished. People’s private rooms and communal areas at the service were clean and hygienic.

The provider did not always make sure that medicines were safe and met people’s needs, capacities and preferences. People did not always receive their medicines as prescribed. We found gaps in the records of administration of medicines including topical medicines such as creams, and the remaining balances of medicines did not always match what would be expected if people had received their medicines as prescribed. For one person we found the wrong dose of medicine had been administered. Staff did not always write the date opened on medicines which required this, this meant there was a risk people could be given medicines which had expired. When people had thickener added to their drinks, to reduce the risk of them choking, this was not always recorded. We were not assured the thickener was added to their drinks as needed. This placed them at a greater risk of choking.

Staff did not always record the time of administration of medicines containing paracetamol. This meant there was a risk that these medicines could be administered before the required gap between doses had passed.

However, we found that medicines were stored securely, and people had their allergies documented on medicine paperwork.

Although we did not identify any harm because of the concerns we identified, we could not be assured that people received their medicines safely as prescribed. This placed people at risk of harm. Prior to the assessment concluding, the registered manager implemented further audits help identify shortfalls and support the safe management of medicines.