Sylvan House Residential 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 breach of legal regulation in relation to good governance and notification of other incidents.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The provider did not always focus on learning and was slow to implement improvements. However, their philosophy of care was to provide people with a secure, relaxed and homely environment in which their care, well-being and comfort is prioritised. The manager explained they wanted to build a workplace where the standard of care is what they would expect for their own family. One staff member said, "We make sure residents are happy and comfortable." Another staff member stated, "This is their home and we are here to look after the residents."

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 commented they had seen improvements recently and stated both the manager and deputy manager were visible and approachable. Leaders were open, transparent and responsive to feedback we provided. There was no registered manager at the time of our assessment, however, the current manager was starting the application process with CQC.

Staff did not always feel they could speak up and that their voice would be heard. Even though staff could give feedback during meetings, surveys or anonymously via the newly appointed freedom to speak up guardian, staff told us actions from feedback were not always recorded oracted upon. One staff member said, "Our suggestions are not listened to." Another staff member told us, "Any concerns are not documented and nothing changes."

There were appropriate whistleblowing and safeguarding policies and procedures in place and posters were displayed in the reception area and staff room.

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. Equality policies were in place. The manager gave an example of reasonable adjustments they had made for one staff member and the manager carried out well-being check-ins. Staff told us everyone was treated equally and had no concerns regarding equality and diversity.

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 securely with others when appropriate. Systems to monitor the quality and safety of the service were not always effective and required further improvements. For example, accidents and incidents were not regularly reviewed or analysed which prevented learning from events. Monitoring behaviour charts were not fully completed, preventing further understanding of behaviours that communicate a need. Although the manager had begun reviewing and updating people's care plans, further work was required to ensure they accurately reflected all people's current needs.

However, other systems of oversight had been implemented, and the provider had a business continuity plan in case of emergencies.

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.

The provider worked with the local authority to ensure people were suitably assessed before being offered a place at Sylvan House care home. The provider also worked collaboratively with health professionals. Referrals to external health professionals were evident in people’s care records. Professionals we spoke with gave positive feedback. One professional said the manager engaged well and when health requests were made, staff actioned these.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

An improvement plan was in place following a local authority quality assurance visit in June 2025, however, we also identified similar outstanding actions which had not been met. For example, gaps in training records, lack of registered manager, lack of incident management and reporting. The provider had introduced new systems and processes to provide better oversight of the service. The manager welcomed our feedback and had started to take action to address the issues identified during our inspection.