Sycamore Lodge

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 changed to good. The provider had strengthened medicines management, including clearer recording of topical creams, and improved care planning for individual needs such as seizure management. Staffing levels and consistency had also improved. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a positive learning culture where leaders and staff usually reflected on incidents and used them to improve care. Managers discussed trends in falls, wounds, safeguarding and infections at monthly quality and clinical governance meetings and introduced actions such as weekly mattress and repositioning checks and weight monitoring. Lessons learned were shared in handover, team meetings and on the “lessons learnt” board. Staff were expected to complete reflections where there were medicine errors, which supported a no blame, transparent approach. Staff described feeling able to raise concerns and said managers were approachable, with one staff member telling us they could, “go and speak to [the manager] if you have a problem” and issues were resolved when raised.

The provider worked with people and healthcare partners to maintain safe systems of care. Pathways supported people as their needs changed, including provision of discharge to assess beds and clear admission checklists completed within 72 hours. Daily “10@10” meetings (A short daily operational meeting to share quick updates and highlight immediate priorities)

and the North Somerset sitrep (A structured written report providing a clear picture of ongoing risks, incidents, and organisational status) enabled managers to review hospital admissions, out of hours issues, maintenance tasks, bed sensor use, repositioning, thickeners and IDDSI levels so they could respond promptly to emerging risks. Staff worked closely with external professionals including the falls team, Parkinson’s team, dietitians, public health during a flu outbreak and community nurses, and adapted care plans accordingly. One relative told us, “If I complain, it is dealt with immediately… the manager is approachable.”

The service used the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) plans to support safe, person centred decision making in emergencies. Staff completed ReSPECT plans through detailed discussions with people and their families, capturing what mattered to them, the treatments they preferred and those that would not be appropriate. Families contributed by sharing the person’s wishes when they could not communicate, explaining cultural or spiritual needs, and attending review meetings after a hospital stay or change in condition. These plans supported decisions about hospital admission and end of life care and were recognised across services, enabling staff, paramedics and hospital teams to act consistently in line with the person’s values. Families were involved in regular reviews to ensure plans remained accurate and up to date.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff understood safeguarding and told us they knew how to report concerns; all allegations and serious incidents we sampled had been referred to the local authority and CQC as required. This included unwitnessed fractures, a deterioration in a pressure ulcer, and a personal safety incident where care plans and checks were increased following the event. Managers held monthly safeguarding deep dives with the local authority to review themes and actions. Leaders introduced electronic incident and safeguarding forms to strengthen audit trails and trained staff so they can add information accurately and managers can quickly spot gaps.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The provider had 59 DoLS applications in place for people who lacked capacity, of which 7 were authorised. Staff monitored conditions and recorded them in care plans. These included restrictions needed to keep people safe, for example support with personal care, administering covert medicines, use of bed or chair and bed sensors, supervision to prevent falls, or limiting access to the community where there were risks.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.People and relatives were usually involved in managing risks and contributing to decisions about care. Many relatives told us staff listened to them and responded when they raised concerns. One relative said staff were, “spot on with his medications” and they now felt more able to enjoy life. Another described the service as “an extension of home… pleasant, friendly and welcoming.”

The service held regular resident and family meetings and shared minutes and updates, which helped keep most people informed. Staff also worked with relatives, GPs and pharmacists when making best interest decisions about more complex areas of care, such as covert medicines or end of life planning. We saw examples where staff adjusted care plans in partnership with families and professionals, including changes to diets so people could safely enjoy preferred foods.

However, some relatives told us they had not always been involved in reviews or kept updated when people’s needs changed. They said their level of involvement varied depending on which staff member or manager led the reviewWe shared the mixed feedback with the provider. Leaders told us they would review their processes to ensure people and relatives experience consistent involvement in care planning and decision making.

The provider identified and managed risks in the care environment and ensured equipment, facilities and technology supported safe care. The environment was generally safe, well maintained and adapted to people’s needs. Inspectors found level, well lit corridors; en suite bedrooms with appropriate aids; and communal areas, including a refurbished atrium, used for activities and socialising.

Fire safety arrangements were in place. These included regular alarm tests, evacuation drills, fire marshal training and up to date servicing of alarms, lifts, hoists, slings and other lifting equipment, with faulty items removed from use. Water systems were managed safely through legionella checks, temperature monitoring and descaling routines.Where we identified issues, such as out of date PEEPs or air mattress settings that did not match people’s weights, managers acted promptly to update records and provided evidence of recent monitoring.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. People, relatives and many staff told us there were enough staff who knew people well. One relative said, “There appears to be enough staff … the team leaders are good … staff that are good are very kind,” and another told us, “The staffing level is fine, they answer the bell quickly … the manager is approachable.”The provider used a dependency tool to match staffing to people’s needs and kept agency use very low. A strong internal bank meant gaps were covered by staff who already knew people. Safe recruitment checks were completed, including Disclosure and Barring Service (DBS) checks and references. Staff received induction, core training and role specific competencies in areas such as manual handling, catheter care, medicines‑ and dementia.

Some care staff, including those responding to the staff survey, reported pressure on the first floor residential unit. They said they were sometimes short‑ staffed or had staff pulled away to support elsewhere, which made care time‑ consuming. Leaders were aware of this and were using governance reviews‑ and falls data to keep staffing levels under review.

Infection prevention and control (IPC) arrangements were not always effective. We found significant gaps in how staff planned and recorded care for people with infection prone devices, such as urinary catheters. A specialist medicines review identified inconsistent documentation of essential catheter related tasks, including use of night bag stands, bag changes, cleaning of drainage ports and checks on leg bag security, despite the recognised risk of catheter associated infection.

Care plans and observational records did not consistently reflect the frequency of personal care, mouth care or hydration monitoring required for people at higher risk of infection or skin breakdown. As a result, good IPC practice was not always delivered or evidenced, creating a high risk of avoidable harm. Although we did not find evidence that harm had occurred, the inconsistencies in planning and record‑keeping increased the likelihood that people could be placed at risk if not addressed.

Environmental cleanliness and laundry processes were generally well managed. There was clear separation of clean and soiled items, appropriate PPE use, effective thermal disinfection and routine cleaning of high touch areas. Inspectors found the home clean, tidy and free from unpleasant odours, and the service had managed a flu outbreak appropriately with support from Public Health.Domestic cleaning schedules showed communal areas and bedrooms were cleaned several times a day, and laundry and sluice rooms followed clear infection control workflows.

Medicines were not always managed or recorded in line with best practice. The specialist pharmacy assessment identified several important weaknesses, including insulin pens not consistently dated on opening, blood glucose meters that had never undergone quality control testing, and test strips past their expiry date. Care plans did not clearly describe how to use continuous glucose monitoring devices or when to administer treatment for hypoglycaemia. Covert medicine instructions were not initially recorded on the electronic medicines system, PRN protocols were incomplete, and topical medicines charts and patch application records contained gaps. Medicines audits also sampled only a small number of people, limiting their ability to identify and address issues. These shortfalls meant medicines management was not consistently safe, placing people at increased risk of avoidable harm.

Despite these concerns, people generally received their medicines as prescribed, and relatives were positive about medicines administration. One relative told us staff were “spot on with his medications,” and inspectors observed time critical Parkinson’s medicines being administered within 15 minutes of scheduled times. Medicines were stored securely, controlled drugs were checked and audited appropriately, and fridge and room temperatures were maintained within safe ranges.