Sycamore Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partner agencies and collaborate for improvement. Staff built relationships with community groups. The registered manager told us how they worked with other healthcare professionals to ensure continuity of care. Health and social care professionals visited the home regularly and were able to assess people following their admission to the home from hospital or home. Staff had access to the tissue viability team, falls team, dieticians and other specialist services as necessary. Staff told us of how they monitored people and used risk assessments to ensure they requested referrals in a timely way. One staff member said, "If someone is having lots of trips or falls, we contact the GP for a referral, also we work closely with the tissue viability nurses, we do have a few people with complex wounds We spoke with two health professionals that work alongside staff at Sycamore Court. They told us, "Staff are good at contacting us when needed, they manage people’s health well," and "Knowledgeable and listen to advice and seem to want to learn.” People received ongoing support from various external health and social care professionals who represented them. Staff and leaders understood their responsibilities to work in partnerships with external care professionals to ensure people received joined up care. There was evidence in the care plans and daily notes the provider had liaised with various health professionals to ensure safe care and treatment for people living in the service. The service was looking at arranging more social trips out for people into the community. During our visit there were children visiting which people enjoyed.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were confident to speak up about concerns and they had numerous opportunities to speak up if needed, at handovers, team meetings and supervision. One staff member said, “I wouldn’t hesitate to raise concerns – we can do it anonymously but I would go straight to the manager.” They were aware of the whistle blowing policy but felt that they could raise issues and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. The provider and registered manager understood their responsibilities under the duty of candour. The Duty of Candour is to be open and honest when untoward events occur. We have received notifications as required. During our assessment we found that the management team were open and transparent. They admitted when things had gone wrong and demonstrated how they had used these to make improvements. People and their relatives confirmed they knew how to complain, and a copy of the complaints policy was available in the home and on the service website. Relatives told us; they would make a complaint if they needed to but would talk to staff first. A record of complaints was held in the service. These included the information on the complaint and how this was responded to. We saw complaints had been responded to and actions taken as necessary.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There were organisational quality assurance and governance systems which were used to improve, sustain and consistently develop the service. However, when the falls audit and nutritional audit had identified a need to review staffing levels there was no outcome of review or whether staffing levels had been increased or not required. This meant that the system had not been used effectively. We also found that the cleaning audits had not reflected the housekeeping staff shortages or the odours that were on-going. The management team worked well as a team to ensure there was oversight and effective governance at the service. There were computerised systems and processes to assess, monitor and improve the quality and safety of the service provided. This included health and safety, accidents, incidents, complaints, medication management and staff documentation. Staff were knowledgeable and could tell us of safeguards put in place to mitigate risk, such as 1-1 support, low level beds and sensors. We discussed individual peoples’ daily notes as they were minimal and did not reflect staff interaction and peoples’ mood. The management team demonstrated a proactive response to any areas of improvement highlighted and valued all feedback to ensure that there was a culture of openness to facilitate ongoing learning. For example, the medicine records for a syringe pump lacked detail of site used and checks to ensure it was working effectively. This was immediately actioned. The leadership team engaged with local partners to ensure that they were kept up to date on best practice. One health care professional said, “They work with us, they are proactive in asking for support when needed in a timely manner.” The manager demonstrated a good understanding of the regulatory requirements. Staff understood their role and responsibilities. They all had job descriptions, contracts and received support from the management team to ensure they had the necessary training.

Not everyone was able to share their experiences, but those that could told us, "Staff assist me to live my best life, I have to stay in bed, but I have all I need, staff help me keep in touch with family and friends,” and “They support me to go in my electric buggy, it means I can still be independent, I can go shopping, it’s my home here.” Relatives told us," They always include everyone in activities,” and "The home really makes a fantastic effort with special occasions, this week it’s for Christmas, lots of fun things happening.” We were also told by some families that more social integration into the community and social events were needed to improve people’s mental health. This was discussed with staff who said there were plans to arrange more trips out when the weather improved. Relatives told us that their loved ones had appropriate referrals to other health and social care professionals when required. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partner agencies and collaborate for improvement. Staff built relationships with community groups. The registered manager told us how they worked with other healthcare professionals to ensure continuity of care. Health and social care professionals visited the home regularly and were able to assess people following their admission to the home from hospital or home. Staff had access to the tissue viability team, falls team, dieticians and other specialist services as necessary. Staff told us of how they monitored people and used risk assessments to ensure they requested referrals in a timely way.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.