Sylvan House Residential 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 breach of legal regulation in relation to staffing.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events and incidents. Lessons were not always learnt to continually identify and embed good practice. This resulted in care plans not always being updated with current information which limited the opportunity to improve outcomes. This was fed back to the manager, who immediately checked all staff knew how to report incidents and created an investigation form to evidence actions taken and lessons learned. We found most complaints were dealt with in a timely manner and relatives told us they were kept informed when concerns arose.

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. The manager explained the pre-admission process and admission forms were completed to ensure people's needs were known prior to moving in. People and their relatives told us moving into Sylvan Home was a smooth process. One relative told us they were fully involved in their relative returning home from hospital. This helped ensure their needs could still be met.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always escalate concerns promptly or appropriately to external agencies. During our review of care records, we identified incidents indicative of abuse that had not been reported through safeguarding procedures, and the Care Quality Commission had not been notified as required.

When we fed this back, the manager took action and submitted all required safeguarding referrals and notifications retrospectively.

There was not always sufficient understanding or application of the Mental Capacity Act (MCA) by staff undertaking mental capacity assessments. Assessments were not consistently decision-specific, and some lacked adequate information about the discussions held with people. In several cases, best interest decisions were not aligned with the specific decision being assessed. We also found inconsistencies within records, including contradictory information about whether a person had capacity in relation to the same decision. We raised these concerns with the provider, who agreed to review and improve how consent and capacity were evidenced and recorded.

Despite these concerns, people and their relatives told us they felt safe receiving support from the provider.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plan reviews were not consistently accurate because incidents of distressed behaviour were not always reported. As a result, people who communicated their needs through distressed behaviours had de‑escalation strategies in place, however, did not have preventative strategies to guide staff in reducing the likelihood of these behaviours occurring. This limited staff’s ability to provide proactive, person‑centred support.

People with diabetes had detailed care plans to guide staff on how to support people with their diabetes management. However, we found one person's plan was missing. New care plan audits were introduced to capture these shortfalls.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Environmental concerns were slow to be rectified. For example, a new gate had been fitted and was without a lock for several months. This meant there was a risk of people leaving and the public accessing the grounds. Areas of the environment were tired and in need of attention. For example, we observed holes in people's bedrooms walls and ripped wallpaper. One staff member told us there was no set schedule for decorating people's rooms and a person told us, "things break down and the fire alarm goes off". The provider had carried out their own fire assessments; however, they could not evidence their competency in fire risk assessments. This meant there was an increased risk the assessment would be ineffective. When we highlighted this, the provider was quick to appoint an external professional service who identified several areas for improvement and an action plan was created. People who smoke did not have a smoking shelter and people were observed smoking at fire exits posing a potential fire risk and blocking emergency exits. When this was fed back, a smoking shelter was installed and maintenance of the environment commenced.

However, we saw evidence of recent health and safety checks and service certificates were in date.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff were not always suitably trained. For example, we found that only 1 out of 20 staff members had completed behaviour support training, despite all staff being required to support a person with identified behavioural needs. This meant the service could not demonstrate that staff had the necessary skills and competence to provide safe and appropriate care. Less than half the staff completed infection prevention and control, fire awareness and manual handling training. Evidence showed 5 staff had not completed the care certificate, an induction framework which covers essential topics to enable staff to provide safe and high-quality care. The manager sourced a new training provider and implemented more robust monitoring.

Staff were recruited safely. People told us call bells were responded to promptly and we observed a constant presence of staff in the communal areas. One relative stated "staff react quickly" when talking about their family member's needs being met. Activities included quizzes and one-to-one games in people's rooms for those cared for in bed. People and relatives commented "staff are lovely".

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Some bedrooms required deeper cleaning. For example, sinks and shower trays were stained. The manager took action and incorporated deep cleans into the cleaning schedule. Not all staff wore PPE appropriately, this was fed back to the manager.

Communal areas were clean and presentable, and staff had sufficient levels of PPE.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Although staff did involve people in planning, including when changes happened.

Staff did not always follow the prescriber's instructions when administering medicines. For example, a medicine was given after food instead of before, which may have reduced how well the medicine worked. When people were prescribed medicines to be given ‘when required,’ some instructions on when to give variable doses was not clear. However, staff recorded whether these medications had been effective. The fire risk associated with the use of paraffin-based emollient creams was not always assessed and recorded in care plans. The manager reacted positively to this feedback and confirmed a full audit of medications would be undertaken and a risk assessment was immediately put in place.

Systems were in place to order, store and dispose of medication. Controlled drugs were stored and recorded appropriately, and fridge temperature monitoring was recorded daily. Staff had completed medicines training and had their competency assessed. We observed staff gaining consent from people prior to medicines being administered. One staff member asked, "Are you ready for your medication?"