Sylvan House Residential Home

Sylvan House is a residential care home providing accommodation and personal care to up to 20 people. The service provides support to older people and younger adults, including those who may be living with dementia. At the time of our inspection there were 19 people using the service.

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

At the last inspection we identified a breach in regulation regarding the management of risk. At this inspection we found that enough improvements had not been made and the provider was still in breach of regulation. For example, some care plans contained inconsistent information regarding people’s needs, and not all care plans contained sufficient information to ensure staff knew how to support them safely and ensure their needs were met. Checks required to ensure the safety of the building and equipment were not always completed regularly and we saw some risks in the environment, such as fire doors that were not working effectively.

At the last inspection we identified a breach in regulation regarding the governance of the service. At this inspection we found that improvements had been made and the provider was no longer in breach of regulation regarding this, although further improvements were still required. New systems had been implemented to help monitor the quality and safety of the service, but they did not identify all the issues we highlighted during the inspection, such as those relating to fire doors and people’s care plans.

Medicines were stored and administered safely. Staff had completed medicines training and most had had their competency checked to ensure they were able to manage people’s medicines safely. However, some newly recruited night staff had not yet completed their competency assessment and temporary arrangements were in place with on-call staff to ensure people would still receive medicines if they needed them overnight.

There was a newly implemented system in place to manage Deprivation of Liberty Safeguards (DoLS), and the manager had begun making relevant applications for people. Although mental capacity assessments had been completed when necessary, further work was required to ensure these were always completed fully and in line with guidance.

People told us they were happy with the cleanliness of their home and that their relatives were supported to visit the home. There were procedures in place to help manage the prevention and control of infections, such as policies, audits and cleaning schedules, but these could be improved. A planned refurbishment of the home was in process, however there were some infection control risks identified. For instance, we saw visibly dirty chairs in the lounge, chipped wood and the basement required work to ensure the area was maintained safely and in line with infection control guidance. Personal protective equipment was available to staff when this was required to be used.

People told us they felt safe living in Sylvan House. There were sufficient numbers of safely recruited staff available to support people and people told us they received the support they needed, when they needed it. Staff knew how to raise any safeguarding concerns they had. Accidents and incidents were reported, and actions taken to help prevent future incidents when possible.

There was no registered manager at the time of this inspection, however a new manager was in post and they were in the process of registering with the Commission. The manager was aware of their responsibilities and working hard to implement new processes in order to achieve the necessary improvements.

Relatives told us the home was managed well and they were always kept well informed about any changes through meetings, newsletters and conversations with staff. Staff told us they were well supported, could raise any issues with the manager and had regular meetings where they could share their views.

The manager worked closely with other health and social care professionals to help ensure people's needs were met. They were aware of their role and responsibilities and was responsive to the issues raised during the inspection.

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 1 March 2022) and breaches of regulation were identified. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found that some improvement had been made, but further improvements were still required, and the provider remained in breach of regulation 12 (Safe care and treatment).

At our last inspection we recommended that the provider review staffing levels to ensure enough staff were available in the event of an emergency. this inspection we found this had been acted on.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. 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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sylvan House on our website at www.cqc.org.uk

Enforcement and Recommendations

We have identified breaches in relation to the management of risk at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Sylvan House Residential is a ‘care home’ providing accommodation, nursing and / or personal care for up to 20 younger and older adults; some of whom lived with dementia. At the time of the inspection 18 people were living at the home.

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

Inadequate and ineffective quality assurance and overall governance measures meant that the provision of care people received was compromised. Quality performance measures were not effectively in place, areas of risk were not safely managed, and regulatory requirements were not complied with.

Routine audits, checks and risk management tools were not completed. We were not assured that overall assurance and governance measures were effectively monitoring the quality and safety of care people received.

People did not always receive a safe level of care and areas of risk were not robustly monitored, reviewed or safely managed. Care records did not always contain the most relevant information, care plans were not regularly evaluated and areas of risk were not regularly assessed.

Not all infection prevention and control (IPC) measures and arrangements were robustly in place. We were not assured that the transmission of COVID-19 was effectively managed. However, the provider was meeting the requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.

Due to the current pandemic, staffing levels caused some difficulties for the provider. Staff shortages meant that routine care staff were often allocated to domestic and kitchen duties and high numbers of agency staff were being used. We have made a recommendation regarding staffing levels and improved recruitment procedures that need to be considered.

People told us they felt safe living at Sylvan House; staff were familiar with the safeguarding procedure. However, we identified that only five out of 13 care staff had completed safeguarding training.

Safe medication practices were in place. However, we identified that topical cream storage required improvement and not all staff medication competency assessments had been completed. Medicines were administered in accordance to their administration instructions, ‘as and when’ (PRN) medicine procedures were in place and controlled drugs were safely managed.

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 ‘good’ (published 19 July 2019).

Why we inspected

We initially carried out an unannounced IPC outbreak; this was to follow up on IPC arrangements and to follow up on concerns we had received in relation to the provision of care being delivered. However, additional concerns were identified and it was agreed that the inspection would be expanded, as a result we conducted an unannounced focused inspection.

We undertook a focused inspection due to the concerns we identified around IPC, staffing, safe care and treatment and good governance as well as additional information of concern we received. We reviewed the key questions of safe and well-led only. We reviewed the information we held about the service. 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.

We looked at IPC 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 coronavirus and other infection outbreaks effectively.

The overall rating for the service has deteriorated to ‘requires improvement’. This is based on the findings at this inspection. We found evidence that the provider needs to make improvements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sylvan House Residential Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified breaches in relation to safe care and treatment and good governance. Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following the publication of this report to discuss how they will make changes to ensure they improve their rating to at least ‘good’, we will request an action plan to understand what they will do to improve the standards of quality and safety and 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.

We found the following examples of good practice.

We were assured that the provider, registered manager and staff members at the home had taken appropriate and effective action to help prevent the spread of infection; and help ensure that people were safe during the COVID-19 pandemic.

The provider and registered manager had acted early in the pandemic and ensured that appropriate policies, risk assessments, record keeping and contingency plans were in place. These had been regularly reviewed and updated as more information became available to ensure they were in line with the latest guidance. Systems at the home had changed and improved during the pandemic which showed a culture of continuous improvement. The registered manager had ongoing oversight of the response to COVID-19 at Sylvan House.

The registered manager had ensured effective use of available testing for COVID-19 for both staff members and people living at the home in line with government guidance. This meant that staff members were tested multiple times each week. Both staff and people living at Sylvan House had been supported to take part in the vaccination program.

Each person’s consent in line with their rights had been assessed in relation to COVID-19 testing and vaccination. This ensured that people were listened to, their rights were protected, and any decisions made on a person’s behalf were done so collaboratively and in their best interests. This process had been completed thoughtfully and in detail.

Safe visits had been facilitated during the warmer months in a garden gazebo and the registered manager had risk assessments and plans for when indoor visiting was to take place. Procedures were in place to ensure that any essential visits to the home took place safely.

Staff showed concern for and supported people with their wellbeing and mental health. Staff supported people to use a variety of different technologies to make video calls with friends and family. The registered manager told us that if a person had no family members; a staff member who was not on duty would also give them a video call, so that they felt included. People had been supported by staff to celebrate special occasions during the lockdown period in creative ways.

Staff at the home made appropriate use of personal protective equipment (PPE). Staff had received training in how to use PPE effectively. The home had good stocks of PPE in convenient places. Additional cleaning took place ensuring that the home was clean.

As part of contingency planning; staff were aware of what action they would take if any COVID-19 infection was identified at the home. The home had plans to be split into zones which would help prevent the spread of infection.

People were admitted into the home safely. Staff were knowledgeable of the safe admission processes in place and had a good understanding of each person’s needs. It was clear that staff had good relationships with people which helped staff support them to remain safe. One staff member told us, “We have done our best and tried really hard to keep people safe.”

Sylvan Residential Home is a residential care home providing personal and nursing care. The home accommodates up to 20 people in adapted premises. It does not provide nursing care.

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

Feedback from people living in the home and visitors was all positive. People had developed positive and friendly relationships with the staff and staff could tell us about people’s likes, dislikes, interests and the support they needed.

Improvements had been made to the environment since the last inspection and additional improvements were planned.

Care plans and risk assessments were person centred and they detailed how people wished and needed to be cared for. However, we found that one care file was audited per month. We discussed that this was not sufficient as risk changes and the current process meant that it would take 20 months to check all files. This was actioned immediately.

People were recruited safely, however documentation did not always reflect the processes taken.

Staff received regular training, received supervisions, attended staff meetings and had regular practice checks.

Medication needs were assessed and medication was only given by staff who were trained to do so. Accidents, incidents, safeguarding and complaints were managed appropriately and monitored by the management.

There was a programme of meaningful activities available for people living in the home and we received positive feedback from people and their relatives regarding this. People and their relatives gave consistent, positive feedback about the service. This included the approach of staff, the food, the events that took place in the home and the accommodation.

The registered manager and provider made effective use of internal and external audits and other sources of information to review and improve practice. People were able to give their opinions on their care service and a range of communication methods were in place to ensure people continued to have this opportunity.

Policies and procedures were in place and updated, such as safeguarding, complaints, medication and other health and safety topics. infection control standards were monitored and managed appropriately. There was an infection control policy in place to minimise the spread of infection, all staff were provided with appropriate personal protective equipment such as gloves and aprons. There was also a series of health and safety checks in place to ensure the building was safe.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 05 June 2018) and there was a breach of the Care Quality Commission (Registration) Regulations 2009: Regulations 16 and 18 because the provider had failed to notify CQC of deaths and other occurrences at the home. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sylvan Residential Home on our website at www.cqc.org.uk.

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.

During our last inspection of the home on 24 February 2017 we found a breach of Regulation 12 of the Health and Social Care Act Act 2008 Regulated Activities Regulations 2014 because medication was not always managed safely. We also found a breach of Regulation 17 of the Health and Social Care Act 2008 Regulated Activities Regulations 2014 because there was no effective auditing system in place to drive service improvements.

During this inspection we found that improvements had been made to the management of medication and that regular audits were carried out to monitor the quality of the service. However, we found a breach of the Care Quality Commission (Registration) Regulations 2009: Regulations 16 and 18 because the provider had failed to notify CQC of deaths and other occurrences at the home.

The home had a registered manager. 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 registered manager was not present during the inspection but the deputy manager and the provider were able to supply the information we required.

There were 13 people living at Sylvan House when we visited. There were enough staff on duty to ensure that people’s needs could be met. Robust recruitment procedures had been followed when recruiting a new member of staff to ensure they were of good character.

All parts of the premises looked clean and there were no unpleasant smells. Maintenance records showed that regular checks of services and equipment were carried out by the home’s maintenance person, and testing, servicing and maintenance of utilities and equipment was carried out as required by external contractors. A programme of upgrading the premises was on-going, however there were areas where prompt action was needed for example in the kitchen and laundry.

Risk assessments were recorded in people’s care notes and plans put in place to reduce the risks. These were reviewed regularly and kept up to date.

The manager had made DoLS applications to the local authority some while ago but none had been authorised. The deputy manager told us that this was being revisited and new applications were going to be made. We recommend that this is done without delay to ensure that people have the protection they require.

People had a choice of meals and malnutrition risk assessments were completed monthly. People at risk were referred to a dietician.

A programme of staff training was in place but not all staff had completed the training.

People who lived at the home told us that the staff provided them with good care and support. We observed that staff were aware of people’s individual needs and provided person-centred care.

People’s personal information was kept securely

We saw information in the care plans about people’s likes and dislikes. The care files we looked at showed that people had access to health professionals as needed. The care plans were written in a person-centred style and were kept up to date.

Regular meetings were held for staff and for people living at the home.

This service was last inspected in April 2015. During this inspection we identified a breach of regulation in relation to assessing people’s capacity to consent to care and treatment. This was because information in people’s care plans relating to the Mental Capacity Act (MCA) was poor quality. The ‘effective’ domain of our report was rated as ‘requires improvement.’ Following this inspection the provider wrote to us to tell us what action they were going to take to ensure this breach was met. We checked this as part of this inspection.

During this inspection we found that some improvements had been made and people living at the home had had their capacity re-assessed for individual decisions and applications to the local authority had been made when needed. However, the capacity assessment was not part of the person’s care plan. When we queried this, we were told that the service had asked people’s psychiatrists to complete the capacity assessments and the service had not been given a copy for their records. The deputy manager had printed of templates of capacity assessments as they had identified this was a problem, and were in the process of completing their own assessments on people.

We saw that the registered manager and the staff team had familiarised themselves with the Mental Capacity Act (MCA) 2005 by attending additional training. The MCA is the legislation that underpins mental capacity and how it is applied in care settings. The provider had improved enough to not be in breach of this regulation, however we have made an recommendation for further good practice .

We identified other areas of concern during this inspection which resulted in two breaches of Regulations in relation to medications and the governance of the home.

A registered manager was in post. 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.

Medication was not always being administered correctly or safely. We observed some poor practice with regards to medication administration, and we saw that medication was not always being stored in the correct packaging. We identified a breach of regulation in relation to this.

The general oversight of the registered manager required improving. There had been very little in the way of auditing since our last inspection in April 2015.

Some audits were taking place in areas such as medication and care planning, however there was a lack of auditing in areas such as infection control, and staff records, such as supervision. The medication audits staff completed, were not completed on a specific day of the month and often five or six weeks would lapse between audits. There were some months missing.

Some of the areas of the home were not clean. The registered manager had however, completed an infection control audit a few days prior to our inspection and had identified some of these areas of concern. Prior to this audit, there had been no other infection control audits taking place, and there was no documented process for deep cleaning in the home. We identified a breach of regulations in relation to the governance of the home.

Supervision records were not as up to date as they should have been, some supervisions had taken place in July for half of the staff, and the registered manager had a schedule in place to ensure all other staff would be supervised in the next few weeks.

There was a process in place to ensure staff were suitably recruited to enable them to work with vulnerable people. This included a police check, (referred to as a DBS) which standards for disclosing and baring service. Two verified references for staff, and proof of identification.

Risk assessments had recently been updated and completed. Risk assessments were well written and explained the risk posed to people and how the staff should support the person, including any particular strategies for staff to follow.

People told us they received enough to eat and liked the food. We saw that people were given a choice about what they ate, and the chef often reviewed the menus with people to ensure they were happy with the choice of meals.

Overall, we found that staff were kind and caring in their approach to people. Staff we spoke with were able to describe people’s individual likes and preferences and explained how they provided diverse and dignified care.

People were able to see external health care professionals to maintain their health and welfare. These appointments were recorded in their care files.

People had care plans in place which were person centred. These contained detailed information about their personal care, needs and choices, information about their nutritional needs, skin integrity and mobility. There was also detailed information about their risks and support management needs.

There was an effective system in place to seek what food and drink people living at the home liked or disliked. A record of people’s preferences was made available to us and there was evidence of such records being kept for each person who lived at Sylvan House. Preferences were reviewed on a monthly basis.

Staff were aware of the home’s whistleblowing policy and told us how they would report any concerns or bad practice.

You can see what action we told the provider to take at the back of this report.

Is the service safe?

People said they felt safe and risk assessments were carried out to identify and manage risks to people who used the service, such as falls, pressure ulcers and malnutrition.

The manager and deputy manager were aware of the Mental Capacity Act and Deprivation of Liberty Safeguards, although no applications had needed to be submitted. This meant that people would be safeguarded if they did not have capacity to make certain decisions.

The home was clean and there were appropriate arrangements in place for laundry and maintaining water safety.

Is the service effective?

Staff were trained and supported to meet the needs of people who used the service. People who lived at the home told us they were confident in the skills and experience of the staff who cared for them. One person said "The carers are very good and the manager is brilliant". A visitor said "It seems a very nice home, the staff are very good and they are always welcoming".

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. One person commented: "I've been here for many years and the care is very good. I like playing bingo and joining in the sing-songs. If I'm not well they always get the doctor straight away".

Is the service responsive?

People's health and care needs were assessed with them, and they were involved in writing their care plans. People's preferences, interests, aspirations and diverse needs were recorded and reviewed and support was provided in accordance with people's wishes. One person said: "I'm quite happy. I mostly look after myself but the staff help me with the things I can't do. I like to bet on the horses and they take me out to the shops and the bookies most days".

Is the service well-led?

People who used the service said that the manager regularly asked them if they were happy with the service. We saw that the home had satisfaction surveys they could send to people who used the service, relatives and visiting professionals, but none had been sent out since 2012. This meant that the provider did not have an effective system in place to regularly assess and monitor the quality of the service.

Some areas of the home were badly maintained, particularly bathroom facilities, downstairs corridors and the exterior of the premises and grounds. The manager had identified the areas that required improvement and a new shower was being installed on the first floor, but improvements were taking too long, which was having an impact on the people who used the service because some toilets were inaccessible and they could not sit outside in the nice weather.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to maintaining the premises and quality assurance.

"Staff always ask me before they do anything."; and

"I'm not forced to do anything I don't want to."

We asked the people we spoke with if they felt comfortable, safe and well cared for. They told us :

"Staff are wonderful, I have been here for a long time and so have most of them.";

"Oh yes, those who need it are well looked after. I do most things myself, but the girls will get shopping if I need it;"

Staff we spoke with said they knew what people liked to eat and what they did not like. Cupboards were well stocked with full fat milk, butter, cream, cheese, eggs and fruit and vegetables. People were consulted weekly about menus which meant they received food they liked and ensured their dietary requirements were met.

We looked at the environment and saw that redecoration work such as replacement wallpaper, paint to woodwork and some new flooring was being undertaken, with plans for further changes. We found the environment to be safe. Staff spoken with said they were happy at work and felt well supported in their role. There was an "open door" culture which meant staff could approach management whenever they needed to. Training was provided appropriate to roles and information about people was recorded and stored appropriately.

'It's very good here',

'We are very well treated'.

People told us they were involved in their care and treatment and were able to make choices in every day living activities such as food choices and level of assistance needed with personal care.

We observed that people were well cared for and treated with dignity and respect. People's needs were assessed, planned and reviewed. We found that the provider monitored and had a complaints process in place and gained views on the service from staff and people who used the service.

Staffing levels were appropriate and safe. Staff were experienced and knowledgeable in the people they were caring for. Staff also demonstrated an awareness and understanding of how to protect people from abuse.