Sycamore Grove 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.

This service is dual registered, this is the first assessment for this service. This key question has been rated Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us they loved their jobs and enjoyed working at Sycamore Grove. A number of staff had worked at the home since it had opened in 2023. We found the values of the organisation were clear and put people at the centre of their support and care. We observed staff demonstrating the provider values through kind, compassionate and respectful interactions, taking time to listen and engage with people in a meaningful way. Staff understood their roles and worked hard as a team to ensure people’s needs were met.

The employment of a new registered manager following a short period without a registered manager in post had ensured consistent and supportive leadership was in place. The registered manager had set up a wellbeing support meeting when they first started in the role. This was facilitated by an independent member of human resources with staff able to arrange one to one appointments to share their views. The registered manager used feedback to identify and address any staff worries or concerns.

Regular staff meetings and supervisions promoted a listening culture and ensured staff were listened to and their feedback was valued.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff benefited from the support of a registered manager and deputy manager who were visible in the service, as well as senior management who visited the home regularly.

The registered manager had worked at Sycamore Grove for approximately 3 months. In this time, they had built a relationship with staff, relatives and people living in the home. They ensured staff were supported and had access to the information they needed to safeguard people and provide the best care possible. Staff, people and relatives spoke positively about the registered manager’s leadership. Staff described the registered manager as approachable, supportive and caring.

The registered manager told us they felt well supported within the organisation. They had been supported by a named mentor who was a registered manager from another service within the organisation. They told us, “I have had amazing support from everyone, but having a mentor has been a real asset. I feel very supported by them and the organisation.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There were clear policies in place for people and staff to follow including a complaints and whistleblowing policy for staff. There was a designated ‘Speak up’ champion in the home who staff could access and speak to in confidence, with speak up information displayed in staff areas. Staff told us they were aware of the speak up champion and felt they would be supported if they raised any concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a robust recruitment process in place to ensure fair recruitment and selection processes. Staff felt they were treated equally. The provider valued equality and diversity and promoted an inclusive and fair workplace. The registered manger told us they took account of individual circumstances and put reasonable adjustments in place when needed.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider and registered manager had highly effective and robust governance systems with a clear framework in place to ensure regular audits were completed. This included all aspects of care and support, accidents, incidents, medicines, health and safety, infection control and catering, as well as continued oversight of the environment and services.

Areas of risk were identified, for example, if audits identified an increase in infections or falls within the home this would be reviewed and addressed with changes implemented promptly.

Audits and quality assurance was used to identify any improvements or learning to be taken forward to facilitate ongoing improvement. Information was fed back to staff to ensure improvements became embedded into practice.

The clinical governance team maintained oversight. Quality improvement visits and mock inspections were carried out, the regional manager confirmed these were used to identify areas where the home was excelling or where improvements were needed.

Regulatory responsibilities were being carried out by the registered manager. Notifications were submitted to external organisations as required, including CQC.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff ensured there was continual collaboration with people their relatives and other health professionals to maximise the delivery of care and support to those living in the home.

Staff worked in partnership with other health and social care professionals to enhance the care provided and ensure people benefited from a wide range of specialist expertise. Visiting healthcare professionals told us, “Overall, I believe we have developed an excellent working relationship based on mutual respect, effective communication, and a shared commitment to providing high-quality care for residents” and “Several members of staff have my email address and regularly contact me for advice when needed or alternatively liaise through the GP practice. This reflects their proactive approach to resident care and effective communication with external healthcare professionals.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had established systems to capture learning and support ongoing improvement. Audit outcomes were reviewed and used to guide improvements and identify lessons learned. The registered manager demonstrated commitment to learning and improvement. Lessons from incidents and safeguarding concerns were reviewed and shared with staff.

The registered manager welcomed feedback to improve people’s outcomes and the quality of service provided.