Sycamore Grove 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.

This service is dual registered; this is the first assessment for this service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a transparent and positive learning culture within the home. This included robust oversight and monitoring of accidents and incidents. Accidents and incidents were routinely reviewed by the management team to identify trends and opportunities for improvement. Information was shared following incidents so that any learning or improvements were implemented promptly and measures taken to keep people safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Relatives told us they had been involved in the assessment and were regularly involved in reviews and kept updated regarding people’s care needs. One told us, “I am always informed about any changes to their health, plus I can look into her health status on the NHS App.”

The provider and registered manager continued to review people’s needs and worked tirelessly to ensure these were met. However, if a person’s needs increased and they required full time nursing care, the home worked with them and their relatives if appropriate to facilitate a move to a nursing home. Staff told us they worked hard to reduce the impact on the person. Relatives confirmed they were aware that nursing care was not provided at Sycamore Grove Care Home. One told us, “The registered manager worked closely with staff to identify and respond to any changes to people’s health.” Concerns were escalated promptly and referrals completed to appropriate health professionals, such as occupational therapists (OT), GPs, community nursing teams, speech and language therapists (SALT) and wound care specialists.

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.

There were robust systems and processes in place to help protect people from harm. Safeguarding policies were in place, staff had completed safeguarding training relevant to their role and demonstrated a good level of knowledge. Management maintained detailed records in relation to any safeguarding concerns. These included actions taken, referrals made and any learning identified.

The provider had ensured people were supported in line with the Mental Capacity Act 2005 (MCA) 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 MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Information in relation to DoLS applications and authorisations were clearly recorded and staff demonstrated a good understanding of MCA and DoLS.

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 told us they felt safe and supported living at Sycamore Grove Care Home. One person told us, “I am settled here, I don’t have to worry about shopping or cooking and there is always someone here to keep me safe If I need it.”

Risk assessment tools were used to determine people’s level of risk. These included risk in relation to, falls, mobility, nutrition, including any risk of choking, as well as any specific risks associated with long term health conditions, for example, for people living with diabetes or dementia. Relatives confirmed they felt people were safe and well looked after, comments included, “I don’t have to worry about them at all, it's so good here.” And “Honestly, I have had no negative experiences whatsoever with the care home or its staff. And I am not easily pleased.”

Care was personalised and tailored to each person's individual needs. Care documentation provided staff with the information needed to deliver consistent safe and effective care. People were supported to manage risks safely while continuing to lead full and rewarding lives.

People had Personal Emergency Evacuation Plans (PEEPs) in place to inform staff and emergency services in the event of an evacuation being required.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home had designated housekeeping and maintenance staff. People and relatives spoke highly regarding the cleanliness and maintenance of the home. One relative told us, “The home is always very clean and tidy, both the communal areas and [relatives] own bedroom. Every single time I have visited their room has always been spotless.”

Sycamore Grove Care Home had large open spaces and access to a large garden. The home was pleasantly decorated throughout, any maintenance issues identified were discussed with management and addressed by the maintenance team, when required external companies were used for specialised work. All equipment and services were regularly maintained.

Visiting health professionals spoke positively about the environment. One said, “The home itself always provides a warm and welcoming atmosphere. It is consistently clean, well-organised and maintained to a high standard, which supports safe and efficient professional visits. Crucially, the residents appear happy, comfortable and well-supported in their environment.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The home had safe and effective levels of staffing. A number of staff had worked at the home since it had opened 3 years ago. Staff spoke with enthusiasm about their roles and working at Sycamore Grove. Staff feedback was consistently positive, with staff telling us they loved their job and enjoyed working at the home, staff also shared how they felt supported by their colleagues and management.

The provider ensured safe and thorough recruitment systems were in place and followed them robustly. New staff completed a detailed induction, training and shadowing of experienced staff.

All staff undertook regular training and told us they received the training they needed to meet people’s needs safely. One told us “We had really good dementia training and dementia days, if anyone moved in with a specific condition they would give us extra training, it is really good. The in house trainer [trainers name] is great, we do training online and face to face always some training going on.” Staff received regular support including one to one supervision, staff meetings and daily handovers.

We received feedback from a high number of people and relatives, and all spoke positively regarding staff and the high quality of care provided.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Robust cleaning schedules were in place and infection prevention and control (IPC) audits were regularly carried out to ensure standards were upheld.

Systems were in place to assess and manage the risk of infection in line with current relevant national guidance. The provider responded promptly to any signs of infection. If an infection risk was identified appropriate measures were introduced to minimise the risk of this spreading.

Staff had access to personal protective equipment and we saw staff using this effectively when required. Staff understood their responsibility to ensure they maintained safe infection prevention procedures.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely and people received their medicines as prescribed. The provider had robust systems in place to ensure medicines were managed safely; to detect errors and take prompt action if any errors were found.

We observed medicines being administered and spoke to staff trained to give medicines. Staff displayed a high level of knowledge and understanding regarding people’s medicines and how they should be given. For example, time specific medicines for long term health needs.

Clear documentation was in place to identify when and how medicines should be administered. This included protocols for PRN (as required) medicines. For example, if a person had a PRN prescription for general pain relief, staff recorded when and why the medicine had been given and its effectiveness. This meant that if a person required regular pain relief this could be identified and reviewed with their GP to see if they required an alternative pain relief or if this should be added to their daily prescription.