The Sycamores and The Poplars

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 is the first assessment for this newly registered service. This key question has been rated 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 governance at the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the registered manager had a clear vision for the home, this had not always been upheld during their absence. The registered manager described a high turnover of staff during this period, which affected the consistency of the culture and expectations within the service.

Although improvements had been made to staffing levels and ongoing recruitment, the registered manager acknowledged it would take time to fully embed the culture and vision across the team. They recognised that staff needed sustained support, guidance and stability to work confidently towards achieving this shared direction.

These shortfalls demonstrated that the provider had not consistently maintained a unified culture or ensured staff were fully aligned with the service’s values and expectations during the manager’s absence.

Not all leaders understood the context in which the provider delivered care, treatment and support. Relatives consistently told us there had been a lack of response to concerns raised with the interim manager, and that issues were not always acknowledged or acted upon. One relative said, “I arrived at a weekend and there was only agency staff at the home. I called the [interim] manager and they didn’t seem bothered.” This demonstrated that leadership was not always proactive, compassionate or engaged with people’s experiences.

The management team acknowledged these shortfalls and had put improvements in place. When agency staff were used, they now received a comprehensive induction to ensure they understood people’s needs and the expectations of the service. Leaders recognised that previous gaps in oversight had affected people’s confidence in the service and had begun taking steps to strengthen leadership presence, responsiveness and accountability.

People and staff told us that since the management change, they felt able to speak up and were confident their feedback and concerns would be listened to and acted upon. They described a more open and supportive culture where raising issues was encouraged and responded to positively.

One person said, “I know I can speak to [registered manager] or [support manager] anytime, they care and try to help.” Staff also told us they felt safer and more comfortable sharing concerns, and that leaders were approachable and took time to understand what mattered to them.

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. Staff told us the senior management team were approachable and supportive with their needs. One staff member said, “Things have improved already, everyone needs are taken into account.”

The provider did not have clear responsibilities, roles, systems of accountability or effective governance. Leaders did not act on the best information about risk, performance or outcomes, and they did not always share this securely with others when appropriate. Governance systems were ineffective and failed to ensure people consistently received safe, high‑quality care.

Audits had not identified the issues found during this assessment, some of which had placed people at risk of harm. Where audits had identified concerns, there was no clear action plan implemented to address them, and managers did not maintain oversight of known risks. This meant issues were allowed to persist without timely intervention, and leaders did not demonstrate the capacity to monitor or improve the quality and safety of the service.

The registered manager acknowledged these concerns and implemented an action plan with timescales for improvement, including evidence of how progress would be monitored and evaluated. However, these actions were recent and had not yet resulted in sustained or embedded improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff engaged effectively with external professionals and followed their recommendations, which were clearly detailed within people’s care plans. This helped ensure people received coordinated support that reflected up‑to‑date clinical guidance and professional input.

People were supported to access medical services when needed, and staff worked closely with GPs, community nurses and other healthcare professionals to ensure people’s health needs were met promptly. Information was shared appropriately, enabling external professionals to understand people’s needs and provide consistent care.

Learning, improvement and innovation were not being met because the provider had not established effective systems to recognise, act on or learn from concerns, risks or feedback. Across multiple areas of the assessment, significant and repeated failings showed that learning was not embedded and improvements were not sustained.

Governance systems were not effective, with audits failing to identify serious issues such as people being left in soiled bedding, inconsistent person‑centred care, lack of dementia‑friendly signage, and risks linked to staffing shortages. Even when audits did highlight concerns, no clear action plans were implemented, and managers did not maintain oversight of known risks. This meant lessons were not learned and poor practice continued.

Leadership was not consistently capable or responsive. The interim manager did not act on concerns raised by relatives, and agency staff were previously left without proper induction, demonstrating a lack of learning from incidents and feedback. Staff and relatives reported delays in responding to call bells, people not receiving choice in meals, and people being woken based on staff availability rather than their preferences. These issues persisted due to ineffective learning and improvement processes.