Archived: Tower Bridge Homes Care Limited - Sycamore Also known as Sycamore Court

Tower Bridge Homes Care Limited - Sycamore is a residential care home, providing care and support for up to 39 older people, including people living with dementia. At the time of our inspection, 25 older people were using the service.

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

There is a history of the provider not meeting regulatory requirements and people being at risk of avoidable harm. At this inspection, we identified a continued lack of governance and oversight by the provider. People remained at risk of unnecessary harm. The systems and processes in place to effectively monitor and improve the quality of the service were not robust. The provider had not taken appropriate steps to ensure they had clear scrutiny and oversight of the service, ensuring people received safe care and treatment. The lack of managerial oversight had impacted on the quality of care provided. The provider had failed to learn lessons from previous inspections and to identify and address breaches of regulatory requirements.

A registered manager had started work at the service in September 2019. A registered manager is a person who has registered with the Care Quality Commission 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 service had not always taken appropriate action about safeguarding concerns. Although staff had received safeguarding training and knew how to report abuse, not all staff were aware of external whistle blowing procedures. Care records were not always accurately maintained to ensure staff were provided with clear up to date information which reflected people’s care and support needs. Risks to people had not always been identified. Where risks had been identified people’s care records had not always been reviewed and, where appropriate, updated. People received their medicines from staff who had received training however, further improvements were required to ensure people received their medicines safely in line with best practice guidance.

Staff completed the provider’s mandatory training but had not received specialist training, which the provider informed us they would be delivering to staff following our last inspection. This meant staff were not equipped with the skills, support and knowledge they needed to provide effective good quality care to people. Although staff felt supported by the registered manager, staff supervision had not been undertaken in line with the provider’s policy following our last inspection up to the date the registered manager commenced employment at the service.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

We made three recommendations to the provider; to review end of life care planning processes in line with best practice guidance when reviewing people’s care; to consider national guidance on the environment for people living with dementia and to review the support they provide for people in relation to people’s capacity.

People, and relatives, were positive about the meals provided, however further improvements were required to improve the mealtime experience for people living with dementia. Documentation used to monitor people’s daily food and fluid intake was not always monitored effectively, placing them at risk of dehydration and/or poor nutritional intake. A range of activities were provided but improvements were required to provide people living with dementia to participate in meaningful activities. One relative told us, “There’s not enough stimulation [on first floor] at all. The activities coordinator stays downstairs and you cannot take [people] downstairs due to risk of absconding. I feel they get forgotten about.”

Staff were kind and caring towards the people they supported, treated them with dignity and respect and empowered them to remain as independent as they were able to. We observed positive, caring interactions between staff and people. People were supported to maintain relationships with people who were important to them and visitors were welcome at the service at any time.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 4 March 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do to improve. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified nine breaches in relation to safeguarding people from the risk of harm and abuse, person centred care, recording of consent and the provider’ continued lack of governance and oversight to ensure people received safe care and treatment.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

People expressed mixed views about their experience of living at Sycamore Court. People told us they felt safe but they did not always feel listened to as feedback was not always acted upon. A very high turnover of managers and staff over the past four years meant that people did not always know who was in charge. Frequent changes in staffing and management meant that planned improvements did not always happen or were not sustained. This was summed up by one person who told us, “I’ve been here four years now, this place has the makings of paradise but [named manager] is hardly ever here, what this place lacks is continuity. The carers change too rapidly, what is the indication as to why they keep changing?”

Historically there had been high numbers of agency staff employed which resulted in a lack of continuity of care. However, recently there had been significant improvements in recruitment with the day shift now covered entirely by regular staff. At night some agency staff were still being used but at much lower numbers than previously. The improvements in staffing meant that the keyworker system had been re-introduced which would help people and staff get to know each other better and build positive relationships.

Safeguarding concerns had not always been raised and investigated appropriately and the information not always shared with the local authority or CQC.Similarly, accidents and incidents were not always followed through with the appropriate action to minimise the risk of re-occurrence. The service was working with the local authority to improve practice in this area.

Peoples medicines were not always managed safely and medicine audits had not been effective at picking up mistakes we found. Improvements to the environment and staff practices were required to support good infection control practices.

Risks to people were assessed though lacked detail. New systems for sharing information on risks to people had been introduced. Monitoring of food and fluid intake had improved but required further improvement.

There were gaps in staff training, supervisions and observations of staff practice. Plans were in place to make the required improvements. Mental capacity assessments and Deprivation of liberty safeguard applications were not always completed appropriately which meant some people were being deprived of their liberty unlawfully. Staff demonstrated an understanding of how to support people to make choices.

People had care plans but these did not always reflect an accurate picture of the person. The system for reviewing care plans was under review to ensure people were included in the process. People were assisted to have enough to eat and drink and said the food was good but the mealtime experience could be improved upon. Staff completed the required tasks but missed opportunities to engage with people.

People said staff were kind and caring but interactions between staff and people were generally task orientated with limited sustained interaction. There were limited opportunities for engagement and stimulation for people living with dementia.

There was a complaints procedure in place and people told us their concerns were dealt with positively. People and staff were positive about the new management team. The management team and provider were extremely open and transparent with us about the current failings of the service and were enthusiastic and committed to turning the service around. New systems and processes were being put in place to support the necessary improvements. However, it was too soon to comment on their effectiveness.

Rating at last inspection: Requires Improvement with breaches of regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulations) 2014. Last report published January 2018.

Why we inspected: At the last inspection, multiple breaches of the regulations were found. We met with the provider to discuss our concerns and an action plan was agreed upon. This was a planned inspection to check on the progress of the service in making the required improvements. At this inspection improvements had been made in some areas, but further improvements were still required. Therefore the rating remains Requires improvement across all five domains with breaches of Regulations 11, 12, 13, 17 and 18 of the Health and Social Care Act 2008 (Regulations) 2014 and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We also made several recommendations to improve the quality and safety of the service.

Enforcement: You can see the action we told provider to take at the end of the report.

Follow up: We will continue to monitor this service and plan to inspect in line with our inspection schedule for those services rated requires improvement.

Following that inspection the provider sent us an action plan, which set out what they would do to meet the legal requirements in relation to the breaches and to improve the service.

We re-inspected the service in October 2017 to check that the necessary improvements had been made. At this inspection we found that whilst there had been some improvement in certain areas, there were still issues of concern and continued breaches of the regulations and the rating remains ‘Requires Improvement’.

This inspection took place on 29 and 30 October 2017 and was unannounced. During the inspection we found breaches of Regulation 9, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result of our concerns we sent the provider an urgent action letter asking them to submit an action plan to set out how they would deal with the issues we found. We then completed a further inspection visit on 22 November 2017 to check their progress.

Sycamore Court is a residential care home registered to provide care and accommodation for 39 older people. There were 35 people living in the service at the time of our inspection. The service was spread across two floors. Upstairs accommodated people with more complex needs related to living with dementia.

There had been a significantly high turnover of managers over several years and this had impacted on the quality, safety and effectiveness of the service. Instability in terms of leadership and a lack of oversight by the provider meant that many of the issues we found during our previous inspection had still not been addressed. There were quality assurance mechanisms in place to measure and improve the quality and safety of the service but these had been ineffective as they had failed to address many of the issues we found.

At our previous inspection a new manager had only recently been appointed and was going through the registration process. However before the process was completed they resigned from the company. We were subsequently notified that the provider had recruited a new manager who has since become registered. A registered manager is a person who has registered with the Care Quality Commission 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 new registered manager had a positive impact on the service and was viewed by people and staff as approachable, accessible and supportive. The registered manager took a ‘hands-on’ approach and any concerns or complaints were listened to and dealt with appropriately. However, due to insufficient support from the provider the registered manager lacked the resources to make all of the required improvements.

The service was struggling to recruit new staff so was using a high percentage of agency staff. This impacted on staffing numbers, deployment of staff and skill mix and meant that people’s needs were not always met safely and effectively in a way that reflected their preferences. People’s experience of being cared for varied considerably depending on which staff was providing the care and support and people did not always feel as if staff knew them well. The high percentage of agency staff used meant that some staff working at the service did not have the knowledge and experience of people to support them effectively.

We made a recommendation that the provider review their system for inducting, supporting and overseeing agency staff.

People had risk assessments in place which were regularly reviewed. However in some instances, specific risks to people had not been identified, assessed and recorded.

During our first two visits we saw that some areas of the service posed a risk to people due to environmental hazards. The registered manager addressed our concerns immediately and at our third visit we found the environment had been made safe.

People’s care needs had been assessed and regularly reviewed. However, improvements were required to ensure all people or their representatives were fully included in the process.

The care provided to people was task-focussed rather than person-centred due to time constraints and staffs lack of familiarity and knowledge about people’s needs. People’s routines and preferences had not always been explored, documented and upheld which meant choice was not always supported.

People and relatives expressed mixed views regarding available opportunities to engage in activities and social interaction. Our observations throughout the inspection showed that there was very little stimulation available for people.

We made a recommendation that the provider review their activities programme.

People's ability to make decisions had not been consistently assessed in line with the Mental Capacity Act, 2005 (MCA) and applications for Deprivation of Liberty Safeguards (DoLS) had not always been completed. However, at our third visit we found that the registered manager had addressed our concerns and the service was now meeting the requirements of the MCA and DoLs legislation.

The service supported people to have enough to eat and drink although this had not always been accurately recorded to effectively monitor people’s nutritional and hydration intake. People's comments regarding the quality of the food was mixed.

The provider responded positively to our concerns, submitting an action plan which was detailed and robust and demonstrated a commitment to improving the quality of care. The provider had commissioned a specialist consultancy to work alongside the registered manager and staff team to support them to drive improvements. On our third visit we saw evidence of actions already taken to address all of the concerns outlined above but it was too soon to measure the impact of the new ways of working.

Staff had received training and regular supervision to support them to be competent in their role. This included training in how to safeguard people from abuse. Staff knew the signs to look for and how to report their concerns. Staff were aware of the whistle-blowing policy and said they would feel confident to speak up if necessary to keep people safe.

There were systems in place to ensure the appropriate management of medicines and people received their medicines safely. Recruitment processes were also robust and staff were recruited safely.

The service had formed positive working relationships with healthcare professionals to support people to remain healthy. However, some people felt that improvements were required to ensure they received treatment in a timely manner.

Staff were kind and caring though did not always have time for sustained interaction with people. People were supported to be independent and maintain relationships with people who mattered to them. Relatives and visitors were made welcome at the service.

Sycamore Court is a residential care home registered to provide care and accommodation for 39 older people. There were 34 people living in the service at the time of our inspection. The service was spread across two separate units. The ground floor unit supported people with mainly physical health needs and mobility difficulties, some of whom received their care in bed and many required the support of two care workers. The first floor accommodated people who were living with dementia.

The last inspection took place in February 2015 at which time the service was rated good in all areas. At that inspection a new manager had just been appointed and was going through the registration process. A registered manager is a person who has registered with the Care Quality Commission 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.

Since the previous inspection two further managers had been appointed. At the time of this inspection we were advised that the latest manager had withdrawn their application for registration and had given notice so the service was once again recruiting for a new registered manager.

We found that the high turnover of managers had resulted in a lack of stable and consistent leadership which was compounded by a lack of provider oversight of the service. This had impacted on the systems and processes necessary to monitor, assess and improve the quality and safety of the service.

Quality assurance checks and audits had been sporadic and were not as robust as they should be. The provider had not recognised the issues we identified during our inspection and had not always identified and taken action where people were placed at risk of harm or where their health and wellbeing was compromised.

There was a lack of mechanisms in place to include people and their relatives in the running of the service and request their feedback to drive improvements.

We looked at how medicines were managed by the service and found good practice guidelines were not consistently followed which posed a risk to people’s safety.

There were systems in place to assess, manage and review risks to people however these were patchy and inconsistent and sometimes lacked detail. Recording of information around risk also required improvement as it was not easy to find the most up to date guidance to keep people safe.

We looked at the staffing levels and found there were not enough staff to meet people’s needs safely and in a way that protected their rights and maintained their dignity. We observed people having to wait to have their needs met. Oversight in communal and private areas to assist people was cursory and inconsistent and placed people at risk of harm.

During the inspection visit we walked around the home to assess the standards of cleanliness and found some areas of the premises were not free from odours and that disposal of waste products was not always appropriate. We have since had assurances from the provider that the necessary action has been taken to address these issues.

Safety checks were carried out but some areas of the home were potentially unsafe to people living with dementia. We highlighted the risks we had identified and the provider has since advised us that the environment has now been made safe for people.

People were supported to see, when needed, health care professionals. Care staff recognised changes to people's physical and emotional well-being and knew how to share this information and request input from external health and social care professionals. However, referrals were not always made or followed up in a timely way.

Improvements were needed in the way the service and staff supported people to lead meaningful lives and to participate in activities of their choice and ability, particularly for people living with dementia.

Staff told us Sycamore Court was a good place to work as there was a strong sense of teamwork and said they felt supported within their role. However, staff felt the quality and scope of the training could be improved upon. From viewing training records we noted that staff training was in the main delivered via E-Learning and was not always up to date. After the inspection we were advised that steps have been taken to ensure all staff training was completed and the provider is exploring external training.

Applications had been made for Deprivation of Liberty Safeguards (DoLS) assessments for some people living at the service. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Discussions between us and the manager highlighted that a review of DoLS applications was required to ensure that people living in the home were not being deprived of their liberty unlawfully.

Staff supported people with decision making and involved them in choices about their care and support and people's consent for day to day care and treatment was sought by staff.

Where appropriate people were enabled and supported to be independent. Staff knew the care needs of the people they supported and people told us that for the most part staff were kind and caring.

The dining experience was positive and people were supported to have enough to eat and drink of their choosing.

People were supported to maintain their relationships with people who mattered to them. Relatives and visitors were made welcome at the service.

Staff understood their responsibilities to protect people from abuse and were aware of the signs to look for and reporting process if they suspected someone was at risk of harm.

Robust recruitment processes were in place to ensure staff were recruited safely.

We looked at staff training records, health and safety checks, staff and resident meeting minutes and records of the checks the provider's representative completed to monitor the quality of the service. We saw that the provider's representative had visited the service to support the acting manager to lead the service in the absence of a registered manager.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service we saw a sign on the door that politely asked visitors not to allow people in or out of the service unless they knew them and it was safe to do so. This showed that reasonable steps were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service and that there were regular staff that they knew and who knew them. They also told us that they would feel able to speak up if they had concerns or worries and felt that they would be listened to. One person who used the service said, 'They definitely ask if it is okay to do things for you. They could take advantage of us quite easily I suppose, but I cannot recall any event where that happened'.

We saw that staff were provided with training in safeguarding vulnerable adults from abuse. This meant that staff were provided with the information that they needed to recognise the signs of abuse and how to respond when they suspected abuse had taken place. Training for staff Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) was planned.

We saw records which showed that health and safety checks in the service were regularly performed to ensure the environment was safe for people to use. We found that people were cared for in a clean environment and they were protected from the risk of infection because appropriate guidance had been followed.

Is the service effective?

Overall, people's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The care records were regularly reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met safely and effectively.

People told us that they received the care they needed. One person said, 'They look after me very well. If I want something I seem to get it'.

Is the service caring?

People told us that staff were caring. One person said, 'The staff are lovely, very caring when they give me a bath and always ask me if they can do things'. Another person said, 'Staff are wonderful, they have a laugh with us, and are kind'.

We observed that staff were kind to people they supported and interacted with people in a caring and professional way. We noted that staff addressed people by name and took time to talk to them and reassure them if they seemed worried or unsure. One person who used the service said, 'If I need help I can ring my buzzer. This place is lovely and the staff are an exceptionally nice crowd.'

Another person who used the service said, 'I love it here. The main thing is the staff, who are excellent without exception. They are helpful, obliging and considerate and do their jobs with a smile'. Visitors told us that they always found the staff to be welcoming, friendly and caring.

Is the service responsive?

People's care records showed that where concerns about an individual's wellbeing had been identified, staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, such as doctors and district nurses.

People who used the service were provided with the opportunity to participate in a range of activities that interested them. People's choices were taken in to account and listened to. We noted that people were offered choices throughout the day, such as whether they would like to have tea or coffee or where to spend their time.

People's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service well-led?

The provider had recently notified us, as required, that the registered manager was no longer working in the service and we received the application to formally confirm this. The provider also told us of the arrangements they had put in place to support the deputy manager to oversee the service while a manager was recruited. Staff told us that they were able to speak to the acting manager when they needed to and that the acting manager was accessible and supportive to the team.

The provider had a quality monitoring process in place to support the acting manager to check the quality of the service. This was used to manage risks and to assure the health, welfare and safety of people who received care at the service. Records showed us that some areas were not checked and actions were not always taken promptly where issues were identified.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make in relation to line management support and guidance.

We saw that care was planned and that staff were aware of the support that people needed. Relatives spoke positively about the home and the care provided to people living there. A visiting health professional also spoke positively about the care provided and the competency and caring nature of the staff team.

People told us that they enjoyed the food served and were offered choices. We found some lack of clarity as to whether all of the people using the service were offered food during the evening. The provider’s representative dealt with this during the inspection, instructing staff to ensure that everyone was offered a range of sandwiches and snacks every evening.

We found that medicines were managed to ensure people’s safety and well being. People had the equipment needed to support their safety and independence. The provider had a clear complaints procedure available. People told us they would feel able to raise any concerns with the staff.