The Sycamores and The Poplars

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 is the first assessment for this newly registered service. This key question has been rated 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 safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not demonstrate an effective learning culture. The provider had failed to act on feedback from people and external professionals, and concerns raised previously by the local authority remained evident during this assessment. These included issues relating to the quality of care, planning and the lack of meaningful interactions and stimulation for people.

The continued presence of these concerns showed the provider had not learned lessons from earlier feedback or taken sufficient steps to prevent recurrence. There was no evidence that learning had been communicated to staff or embedded into practice. As a result, the same shortfalls persisted and continued to impact people’s experience of care.

People experienced safe and well‑coordinated care when moving between different parts of the health and social care system. Staff followed clear processes to ensure important information about people’s needs, risks and preferences was shared with external professionals. For example, hospital passports were completed and kept up to date, providing hospital staff with essential details about people’s communication needs, health conditions, medicines and what helped them feel safe. This supported smoother transitions and reduced the risk of people experiencing distress or unsafe care during hospital admissions.

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 share concerns quickly and appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. Where people receive support in their own homes, this can be done through The Court of Protection which is defined as 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 deprivation of liberty within the service. We found that the principles of the MCA were being met and care plans contained detailed assessments of people ability to make informed decision and clear guidance for staff.

However, people and their relatives told us they had raised concerns to the previous interim manager about the standard of care they received and gave examples of being left in dirty and spoiled clothing due to staff availability. There were no incident forms to support these concerns had been responded to or reported to the local authority and CQC as required.

The provider did not always work well with people to understand and manage risks. Staff did not consistently provide care that was safe, supportive or enabled people to do the things that mattered to them. People were not always involved in discussions about how risks could be managed in a way that promoted their independence and protected their wellbeing.

Identified risks were not always managed effectively. For example, where people required repositioning to protect their skin integrity, this was not always completed in a timely way or in line with their care plans. This meant people were placed at increased risk of pressure damage, and staff could not demonstrate they were supporting people safely.

These shortfalls showed the provider had not ensured staff understood how to work collaboratively with people to manage risks in a person‑centred way. As a result, people did not consistently experience care that balanced safety with choice, control and autonomy.

The provider detected and controlled potential risks within the care environment. They made sure equipment, facilities and technology supported the delivery of safe care, and systems were in place to ensure the environment remained well maintained and compliant with legal requirements.

There was a dedicated maintenance team who completed all required checks, including legionella testing and statutory safety inspections. Records showed these were carried out within expected timescales and any actions identified were promptly addressed. Staff told us they felt confident raising environmental concerns because the maintenance team were responsive to improvements needed and ensured these were completed safely.

People lived in an environment that was clean, well‑kept and supported their safety. Equipment used to support people’s care was serviced regularly, and faults were dealt with quickly to reduce risks. The maintenance teams oversight processes ensured environmental risks were monitored and acted upon, contributing to a safe and well‑managed setting.

The provider did not always make sure there were enough qualified, skilled and experienced staff to meet people’s needs safely. Staffing arrangements were not consistently effective, and staff did not always receive the support, supervision and development required to carry out their roles confidently. As a result, staff did not always work together well to provide safe care that met people’s individual needs.

People and staff told us that, under the interim manager, staff had been required to carry out cleaning and cooking duties due to the absence of a chef and domestic team. This reduced the time staff were able to spend supporting people with their care needs and limited opportunities for meaningful interaction. Staff said this had impacted their ability to provide person‑centred care and maintain safe routines.

The registered manager acknowledged these shortfalls. On returning to the service, they worked with the provider to employ a cook and were in the process of recruiting a domestic team to ensure improvements were made. While these actions demonstrated a commitment to addressing the issues, they had not yet been fully embedded, and staffing arrangements had not consistently supported safe and effective care.

The provider did not always assess or manage the risk of infection effectively. They did not consistently detect and control the risk of it spreading, nor did they always share concerns with appropriate agencies in a timely manner. Shortfalls in environmental safety and IPC oversight meant people were not always protected from avoidable harm.

For example, hazardous waste was stored in a specialist clinical waste bin that should have been locked at all times. During the assessment, we found the lock on the bin was broken, and the external area where it was stored was freely accessible to members of the public. This posed a risk of accidental exposure to infectious waste, environmental contamination, and unauthorised access to materials that should be securely contained.

These issues demonstrated that the provider had not ensured robust IPC systems were in place or that staff were consistently following safe waste‑management procedures. As a result, people, staff and visitors were not fully protected from infection risks within the environment.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning their medicines, including when changes occurred, and ensured people understood how their medicines supported their health and wellbeing.

People received time‑specific medicines when needed, and staff followed clear guidance to ensure these were administered safely and consistently. Records for ‘as needed’ medicines were detailed and clearly documented each time they were used. This meant staff understood when people required additional support, such as pain relief, and ensured these medicines were given safely and only when appropriate.

The medicines room was clean, tidy and well organised, supporting safe storage and preparation of medicines. Staff completed daily temperature checks to ensure medicines were stored within safe parameters, and regular stock checks were carried out to maintain accuracy and prevent errors.