Sycamore Cottage Rest Home Limited

Sycamore Cottage Rest Home Limited is a residential care home providing personal care and accommodation to up to 20 people. The service provides support to younger and older adults living with dementia or a mental health diagnosis. At the time of our inspection there were 15 people using the service.

The care home accommodates people in single bedrooms over two floors of a converted residential building. There is a stairlift for people to access the second floor. The communal facilities include two lounges and a dining room. There are communal gardens at the rear and side of the home.

People’s experience of using this service and what we found

Overall people were happy with the care provided, although they wanted to see more activities, especially a knitting club. They told us they were cared for safely and received their medicines as required. They also told us the home was clean. They felt they could speak with staff and the deputy manager.

The provider had identified improvements were needed to ensure people received their medicines safely through their medicine audits and action was taken. Staff were updating their medicines training on the day of the site visit.

We were assured by most aspects of the provider’s infection control processes. However, there was pressure on cleaning staff which was being addressed. Although the home was visibly clean, there were gaps in some cleaning records. Actions have been taken to address this.

People had the equipment they required to ensure the safe provision of their care, relevant safety checks were completed and any repairs arranged as required. The building was secure for people’s safety and where restrictions were in place upon people’s freedoms, legal authority had been sought.

There had been a change in management, the registered manager had recently left. There were suitable arrangements in place whilst the provider recruited a new registered manager.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 5 February 2020).

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about medicines, infection control, equipment and a change in management. The overall rating for the service has not changed following this targeted inspection and remains good.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Sycamore Cottage Rest Home Limited (Sycamore Cottage) is a residential care home providing personal care to 15 people at the time of the inspection. The service can support up to 20 people.

Accommodation was provided over two floors of a converted residential dwelling, with a stair lift that provided access to the second floor.

People’s experience of using this service and what we found

An aspect of medicines administration required improvement, to ensure if a medicine was dropped during administration then it was disposed of immediately. The provider had already arranged medicines training for all staff and further relevant measures were taken during the inspection to reduce the risk of repetition.

There had been staffing issues and the provider was taking the correct action to address this for people. In the interim, the provider used regular agency staff to ensure there were enough staff to cover the staffing roster.

Potential risks to people were assessed and measures were in place to manage them. People were safeguarded from the risk of abuse and any learning from incidents and investigations were shared with staff.

Overall people were happy with the service they received, their feedback included; “yes they are very helpful” and “they are good in their services.”

The registered manager monitored the culture of the service and had a good understanding of the challenges and improvements required. They understood their role and responsibilities and were supported in their role. People and staff’s views on the service were sought. Processes were in place to enable the registered manager to monitor the service. The service had good links with key agencies such as the local authority and the clinical commissioning group.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 14 February 2019).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about medicines, staffing, falls and records. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with an aspect of medicines administration, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led. We have found evidence that the provider needs to make improvements in the key question safe. Please see the key question safe section of this report.

No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has not changed following this inspection and remains good.

We have found evidence that the provider needs to make improvements in the key question safe. Please see the key question safe section of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sycamore Cottage Rest Home Limited (Sycamore Cottage) on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Sycamore Cottage Rest Home Limited (Sycamore Cottage) is a 'care home'. People in care homes receive accommodation and nursing or personal care, as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Sycamore Cottage provides care for up to 20 older people living with differing stages of dementia. There were 11 people living at the home on the first day of our inspection, with one person receiving treatment in hospital. On the second day another person was supported to move into the home. Accommodation was provided over two floors of a converted residential dwelling, with a stair lift that provided access to the second floor.

At our inspection in November 2017 we found that the provider had acted on the risks and shortfalls that had been previously identified, to ensure people were safe. Whilst we recognised that improvements had been made to the service’s systems and processes for maintaining standards and improving the service; many of the changes were still a work in progress and had not yet been sustained. At this inspection the provider demonstrated that the required improvements had been sustained and had become embedded in practice.

The home was consistently well-managed by the home manager who provided clear and direct leadership. Staff consistently told us the management team had created a supportive environment where their opinions and views were discussed and taken seriously, which made them feel their contributions were valued.

Quality assurance systems monitored the quality of service being delivered, which were effectively operated by the management team, to drive continual improvement in the service.

People experienced care that made them feel safe and were protected from avoidable harm and discrimination. When concerns had been raised, thorough investigations were carried out, in partnership with local safeguarding bodies.

Risks were assessed, monitored and managed effectively. Staff were aware of people’s individual risks and how to support them to remain safe.

There were sufficient staff to respond quickly and provide safe and effective care to people. The home manager operated a robust recruitment process, based on relevant pre-employment checks, which assessed the suitability of candidates to support older people and those living with dementia.

The provider proactively reviewed all accidents and incidents and acted to reduce the risk of a future recurrence.

People's dignity and human rights were protected, whilst keeping them and others safe. Staff supported people who experienced behaviour which may challenge others sensitively, in accordance with their positive behaviour support plans.

People received their prescribed medicines safely, from staff who had their competency to administer medicines assessed annually. People's medicines plans were reviewed regularly to ensure they still required the medicines they were prescribed.

High standards of cleanliness and hygiene were maintained throughout the home, which reduced the risk of infection. Staff followed the required standards of food safety and hygiene, when preparing, serving and handling food.

The operations manager and home manager ensured staff had an effective induction, ongoing training and support to maintain necessary skills and knowledge to support people effectively.

People were supported to eat and drink enough to protect them from the risk of malnutrition and dehydration. Risks to people with more complex nutritional needs were promptly referred to relevant dietetic specialists.

Each person had an individual health action plan which detailed the completion of important monthly health checks. People were promptly referred to external services when required, which maintained their health.

The home had not been originally designed to promote the independence and safety of people who live with dementia. However, the operations manager had developed a strategy to deliver environmental improvements to signage, decoration and lighting. At the time of inspection, improvements to signage had been made to enable people to find their own rooms more easily.

The management team had ensured people’s ability to make decisions was assessed in line with the Mental Capacity Act 2005 (MCA). People’s human rights were protected by staff who demonstrated a clear understanding of consent, mental capacity and Deprivation of Liberty Safeguards legislation and guidance.

Staff consistently treated people with compassion, kindness and respect. Staff spoke about people with pride and fondness, recognising people’s daily achievements, which demonstrated how they valued them as individuals. Relatives consistently reported that staff interaction with their loved ones had a positive impact on their well-being and happiness. People were supported to follow their interests and hobbies which enriched their lives.

People’s choices and independence were promoted by staff supporting and encouraging them to do things themselves. Staff supported people to develop friendships within the home and maintain close links with their loved ones. This protected them from the risk of social isolation and loneliness.

People actively contributed to their care planning. Care plans were personalised and contained information such as the person’s life history, preferences and interests. People living with dementia had assessments relating to memory, mood, interactions and behavioural tendencies.

There were regular opportunities for people and staff to feedback any concerns at review meetings, staff meetings and supervision meetings. People and their relatives knew how to complain. The registered manager used concerns and complaints to drive improvement within the home.

People were supported with care and compassion at the end of their life to have a comfortable, dignified and pain-free death. Staff were thoughtful and consistently treated relatives with kindness, which made them feel involved, listened to, and informed, in the last days of their loved one’s life.

The home manager collaborated effectively with key organisations and agencies to support care provision, service development and joined-up care, for example; local GPs and community mental health and nursing teams.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The registered manager had left the home in November 2016 and Sycamore Cottage did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. At this inspection the home had a new manager who had been appointed on 6 September 2017. The new manager was being supported by an external management consultant and the deputy manager. The new manager had commenced the process to become the registered manager with the CQC.

On 2 and 3 March 2017 we inspected Sycamore Cottage Rest Home Limited and judged the provider to be in breach of seven regulations. We served a warning notice on the provider to make necessary improvements to ensure people received safe care and treatment. On 7 and 8 June 2017 we completed a focused inspection of Sycamore Cottage Rest Home Limited and found required improvements in relation to the warning notice had been completed so people experienced safe care and treatment.

After the inspection on 2 and 3 March 2017 we imposed four conditions on the provider’s registration. These were to ensure, people were safeguarded from avoidable abuse and improper treatment; the provider had appropriate processes to assess and monitor the quality of their service; the provider maintained accurate records of the care provided to people and decisions made relating to their care; the provider only employed fit and proper persons; and staff had all received the necessary training and support to carry out the duties they were employed to perform. At this inspection we found the provider had complied with all of the conditions imposed on their registration.

Since our inspection in March 2017 the manager of the home had sent weekly reports with action plans detailing the improvements to be made and progress that had been made. The conditions imposed on the provider’s registration required the provider to submit monthly reports to us detailing all training provided to staff; audits of all safeguarding incidents; recruitment checks; all medicine errors and medicines management; all bruising incidents; behaviours that challenge incidents; infection control; care plans; staff guidance and CQC notifications. The manager had effectively completed all relevant action plans and the requested monthly reports, which demonstrated all of the required improvements had been made.

At our inspection in March 2017 the provider was not meeting the regulations in relation to obtaining valid consent to people’s care and providing person centred care. We asked the provider to send us a report detailing what action they were going to take to make necessary improvements. At this inspection we found the provider had made the required improvements and ensured valid consent was sought from people who consistently received person centred care.

At this inspection we found that the provider had acted on the risks and shortfalls that had been previously identified. Whilst we recognised that improvements were being made to the service’s systems and processes for maintaining standards and improving the service, many of the changes were still a work in progress and have not yet been sustained in the longer term to be fully embedded in practice. The improvements that have already been made will need to be sustained to demonstrate that the service has improved and continues to do so without the additional provider support and oversight and any increase in placements at the service. At the time of this inspection the service was just over 50% occupied. It is too early to state that the improvements are sustainable.

People were protected from the risks of potential abuse by staff who knew what actions to take if they felt people were at risk. The home had effective safeguarding systems, policies and procedures and managed safeguarding concerns promptly, using local safeguarding procedures whenever necessary. The manager had embedded a proactive approach to anticipating and managing risks to people which was recognised to be the responsibility of all staff.

Staff had the right mix of skills to make sure that people experienced safe care. The manager regularly reviewed staffing levels and adapted them to meet people’s changing needs. Staff had undergone pre-employment checks to assess their suitability to provide support to vulnerable people. Staff managed people’s prescribed medicines safely in accordance with relevant national guidance. Staff had been trained and understood their role and responsibilities to maintain high standards of cleanliness and hygiene in the premises to reduce the risk of infections.

The manager encouraged openness and transparency when things went wrong. Staff understood their responsibilities to raise concerns and report incidents and near misses. In the context of this report a near miss is any unsafe event that results or could have resulted in personal injury or damage to property or equipment.

The manager had ensured that staff had the skills, knowledge and experience to deliver effective care and support to meet people’s needs. Staff consistently supported people in accordance with current best practice, for example; when supporting people to move and transfer. Supervision and appraisal were used to develop and motivate staff, review their practice and focus on their professional development.

The service protected people, especially those with complex needs, from the risk of poor nutrition, dehydration, swallowing problems and other medical conditions that affect their health. The service had clear systems and processes for referring people to external services, which were applied consistently. Staff made prompt referrals to health professionals when required and acted swiftly on their recommendations.

People and their families had been consulted about decisions regarding the premises and their personal environment. Staff upheld people’s rights to make sure they had maximum choice and control over their lives, and support them in the least restrictive way possible.

People were consistently treated with dignity, respect and kindness by staff who made them feel that they mattered. The manager ensured staff had the time, information and support they needed to provide care and support in a compassionate and person-centred way. Staff noticed quickly when people were in discomfort or distress and took swift action to provide the necessary care.

People were empowered to make choices and have as much control and independence as possible. The provider complied with the Accessible Information Standard by identifying, recording, sharing and meeting the information and communication needs of people with a disability or sensory impairment.

People were confident that if they complained they would be taken seriously, and their complaint or concern would be explored thoroughly. The manager used the learning from complaints and concerns as an opportunity to drive improvement in the quality of the service.

People were sensitively supported to make decisions about their preferences for end of life care. Staff were aware of national good practice guidance and professional guidelines for end of life care.

The managers leadership, governance and culture had promoted significant change and the delivery of good quality, person-centred care. The manager had implemented clear and effective governance, management and accountability processes. Staff understood their role and responsibilities, and were motivated by their leaders who inspired confidence. The manager involved people, their family, and staff in the development of the home in a meaningful way. Quality assurance arrangements were robust and identified current and potential concerns and areas for improvement. Concerns had been investigated by the manager in a sensitive and confidential way, and lessons had been shared and acted on. The manager worked in a collaborative and open manner with all relevant external stakeholders and agencies to support and improve people’s care provision.

Sycamore Cottage Rest Home Limited provides care for up to 20 people living with differing stages of dementia. There were 19 people living at the home on the days of our inspection. Accommodation was provided over two floors of a converted residential dwelling, with a stair lift that provided access to the second floor.

The registered manager had left the home in November 2016 and Sycamore Cottage Rest Home Limited did not have a registered manager in place on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated

Regulations about how the service is run. Following the inspection the registered provider informed us that a new manager had been recruited and they would be starting in April 2017 to ensure the registered provider would meet their registration requirement to have a registered manager in place. The deputy manager had fulfilled the role of interim home manager since November 2016.

We found an effective governance system to monitor the quality of the service and identify the risks to the health and safety of people was not in place. A regular programme of audits had not been completed in relation to the management of people's medicines, infection control practices, health and safety and quality of care records. The interim home manager and the registered provider had not identified the areas of concern we had found. As a result, action had not been taken to improve the quality of care and ensure the safety of people.

We found people's safety was being compromised in a number of areas. Risks to people in relation to the use of medicines, equipment, malnutrition, behaviour and the environment had not always been assessed and risk management plans in place were not sufficient to enable staff to keep people safe.

People's care records did not include all the information staff would need to provide people's care and when people received care this was not always recorded. Staff and the interim home manager could therefore not judge from people's records whether people had received their care as planned and their medicines as prescribed.

Medicines were not managed safely or administered and recorded appropriately to ensure people received their medicines as prescribed.

Staff had not received the support, induction, guidance and training to develop their skills and knowledge to ensure they could meet people’s needs and keep them safe. We found the support provided to people living with dementia did not always meet their needs and preferences.

Recruitment arrangements were not safe. All the information required to inform safe recruitment decisions was not available at the time the provider had determined applicants were suitable for their role.

Improvement was needed to ensure staff would always identify potential abuse, including neglect, so that action could be taken to report and investigate these concerns to protect people from potential harm.

Where people lacked the mental capacity to make informed decision, or give consent to their care, the registered provider did not always act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice to ensure people’s right were upheld.

People's privacy and dignity were respected and they were complementary about the caring relationships they had built with staff.

Opportunities were available for people and their relatives to provide feedback about the service and this was taken into consideration when making improvements to the service.

People were supported to access the GP and offered a balanced diet.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Following this inspection we wrote to the provider to request a plan of action setting out how they would address the immediate and urgent concerns identified at our inspection. We received an action plan from the provider that indicated that they had already started to take action to address the identified concerns.

We identified seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We found people's safety was being compromised in a number of areas. Risks to people in relation to the use of medicines, equipment, malnutrition, behaviour and the environment had not always been assessed and risk management plans in place were not sufficient to enable staff to keep people safe.

People's care records did not include all the information staff would need to provide safe care and when people received care this was not always recorded. Staff and the interim home manager could therefore not judge from people's records whether people had received their care as planned.

Medicines were not managed safely or administered and recorded appropriately to ensure people received their medicines as prescribed.

These circumstances were a breach of Regulation 12 (Safe care and treatment) of the HSCA 2014. The provider was served with a warning notice in relation to safe care and treatment which they were required to meet by 5 May 2017. We told the provider they needed to take action to meet all their legal requirements and we received a report setting out the action they would take to meet the regulation.

At this inspection, we found that the provider had followed their plan and the legal requirements in relation to providing people with safe treatment and care had been met.

This report only covers our findings in relation to this legal requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Sycamore Cottage‘ on our website at www.cqc.org.uk. Other regulations which need to be considered to judge whether a service is safe were not considered during this inspection.

Sycamore Cottage Rest Home Limited (to be referred to as Sycamore Cottage throughout this report) provides care for up to 20 people living with differing stages of dementia. There were 15 people living at the home on the days of our latest inspection. Accommodation was provided over two floors of a converted residential dwelling, with a stair lift that provided access to the second floor.

The registered manager had left the home in November 2016 and Sycamore Cottage did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The deputy manager had fulfilled the role of interim manager since November 2016. At this inspection the home had a manager who had been appointed from 1 May 2017. The new manager was being supported by an external management consultant and the deputy manager. The manager had commenced the process to become the registered manager with the CQC.

The provider had taken action to fully review and reorganise the processes and procedures to ensure the safe management of people’s prescribed medicines. The manager had completed competency assessments of most staff trained to administer medicines. Competency assessments for two remaining members of staff were scheduled to be completed immediately following the inspection.

People were protected from the risks of avoidable harm associated with the use of moving and positioning equipment fully serviced by qualified engineers. Staff had recently completed moving and positioning training with focus on how to use specific equipment to meet people’s individual needs.

People were protected from the risk associated with their skin breaking down by staff who provided care in accordance with people’s pressure area management plans.

The manager had identified people who displayed behaviour which may challenge others and had updated guidance in their support plans documenting how staff could manage these behaviours safely. Consistent sensitive interventions by staff, in accordance with the guidance within people’s support plans, kept people safe when they displayed behaviour which may challenge others.