Sycamore Rise Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in continued breach of legal regulation in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider sought to share their vision of providing a compassionate and individualised service that celebrated people’s individuality. Staff told us they felt positive changes had taken place since the registered manager had joined the service. They said they felt supported and involved in improving the service and they considered they worked well as a team. The registered manager supported staff to understand the aim of the service, which was to deliver good care which met people’s needs and promoted their rights. Staff told us the registered manager spent time with them sharing information on best practice and documentation was available for staff to refer to.

The provider employed a registered manager who worked with other stakeholders, people and relatives to improve the service. Relatives said the registered manager was approachable and sought to engage with them. They shared the registered manager was available if they needed to speak with them on an individual basis, and that group meetings had been arranged to allow relatives and people to come together and share their experiences with the registered manager. Staff told us they had meetings and discussions with the registered manager where they were able to seek clarity and bring ideas for consideration. A staff member commented, “[The registered manager] has had to turn a lot of things around, we are getting back on track.”

The provider supported a positive culture where people felt they could speak up and their voice would be heard. Staff told us they would enable people to raise concerns by sharing this with the registered manager. Staff were aware of their right to speak up and said they were confident the registered manager and provider would respond positively if they did so. A staff member said of the registered manager, “She listens, she acts. I’d speak up.”

The provider had a supportive culture which valued staff. Staff told us they felt valued and were confident the registered manager and provider promoted inclusion and equity. Staff could give examples of how their individuality was recognised and their rights upheld. One staff member shared how they had needed extra support in an area of their work, this was provided. A further staff member described how they felt when completing some training. They said, “I felt really helped and looked after.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this with others when appropriate. Audit systems were not effective to drive improvement. Audits had not identified the concerns we found with the management of infection control, care records, recruitment records, medicines and window restrictors. Audits carried out by walking around the home were not documented. This meant opportunities to improve and manage associated risks and quality of care were missed. The provider had failed to address aspects of good governance and concerns identified at previous inspections. The registered manager responded to our feedback and introduced new audits where this was required.

The provider understood their duty to work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The registered manager was working with external stakeholders to improve the service and told us they welcomed any guidance and support that would positively impact people’s experience.

The provider did not have effective processes in place to support continuous learning, innovation and improvement across the organisation and local system. The provider had not consistently ensured learning and improvement since the last inspection had taken place and effective changes had not been successfully implemented. Insufficient improvements had been made and the service remained in breach of legal regulations. We shared our findings with the registered manager and provider who acted quickly to make improvements to the concerns we had found.

We found some evidence that the provider sought to learn and improve. For example, we noted falls awareness training had been provided to staff to increase staff knowledge in this area and minimise the risk of falls. We shared our findings with the registered manager and provider who acted quickly to make improvements to the concerns we had found.