CQC report explained · a residential care home
What the CQC found at 56 Sycamore Grove
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks such as burns, scalds and fire evacuation had been assessed, with measures for staff to follow. Medicines were stored, administered and recorded safely.
- Effective?
- Good
- Staff had training linked to people's needs, including epilepsy training, and people were supported to use health services. Mental capacity was assessed, but records did not always show how people had been involved in decisions.
- Caring?
- Good
- Staff knew people's communication, needs and preferences. People were supported to make choices, maintain privacy and independence, and spend time in ways they preferred.
- Responsive?
- Good
- Care plans reflected people's likes, dislikes, beliefs and choices. People helped plan activities and were supported to build independence and maintain family relationships.
- Well-led?
- Good
- The registered manager had improved care planning and quality checks after the previous inspection. The manager worked alongside the staff team and involved families, people and staff in the running of the home.
What inspectors found, June 2019
Ordinary Life Project Association - 56 Sycamore Grove was rated Good, with improved care plans, safety systems and person-centred support.
This was an unannounced comprehensive inspection on 7 May 2019. One inspector spoke with both people living at the home, reviewed care and management records, and spoke with the registered manager and one staff member.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that risks were assessed, medicines were managed safely, staff had suitable training, and people were supported with their health, food, activities and family relationships.
The home had improved since the previous inspection in February 2018, when it was rated Requires Improvement. Earlier breaches relating to risk assessments, medicines, mental capacity decisions, care planning and quality checks had been addressed. Inspectors noted one remaining weakness in how people's involvement in some mental capacity decisions was recorded.
Personalised care plans
Care plans reflected people's interests, wishes and preferences. People were involved in creating and reviewing them.
“People had individualised care plans in place. These documented their interests, wishes and preferences.” from the report
Improved safety
Safety risks were assessed and staff had clear measures to reduce them. The home had also addressed earlier problems with medicine protocols.
“Risks were identified and assessed. This included, risks of scalds and burns, as well as evacuation during a fire.” from the report
Activities and independence
People took part in activities based on their interests and worked on everyday skills. They were supported to make choices about how they spent their time.
“People attended social activities based on their interests and to build independence skills.” from the report
Family involvement
Families were welcomed and helped to stay in contact. Relatives were included in care planning meetings and feedback.
“People were supported to maintain good family relationships. Family members were welcome to visit the home and staff helped to facilitate phone calls.” from the report
Improved leadership
The manager had acted on the previous inspection findings and improved care planning and quality checks.
“Following the previous inspection, the registered manager had made improvements.” from the report
Mental capacity records
needs fixingAlthough mental capacity assessments were in place, records did not consistently show the questions asked or how people responded. This could make people's involvement in decisions less clear.
“There was not consistently records of the questions people had been asked and how they had responded.” from the report
Garden redevelopment
minorThe home had plans to make the garden more accessible, but this work had not yet been completed at the time of inspection.
“There were plans to redevelop the garden to make it more user friendly.” from the report
- 01How do you now record the questions asked and the person's responses during mental capacity assessments?
- 02What is the current timetable for making the garden more accessible?
- 03How will you involve our relative and the family in reviewing the care plan?
- 04What epilepsy training and person-specific guidance will staff use for our relative?
- 05How will you support our relative to choose activities and develop independence skills?
This was an unannounced comprehensive inspection covering all five CQC questions and both the premises and the personal care provided. This explanation was written from the published report of 13 June 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2018
Rated Requires Improvement; inspectors found kind and supportive care, but serious gaps in records, risk assessments, consent and care planning.
This was an unannounced inspection on 28 February 2018. One inspector spoke with two people, three staff members and managers. They reviewed care records, daily notes, staff training, rotas, policies and quality checks. There were three people living in the home.
People told inspectors they felt safe and that staff were kind. Staff understood people's needs, supported them with health care, meals, activities and community life, and respected their privacy. Staffing levels were considered sufficient, and medicines were mostly managed safely.
However, risk assessments and care plans were often old, incomplete or inconsistent. Some medicines to be given when needed did not have enough guidance. Mental capacity assessments had not been completed for some complex decisions before applications to restrict people's liberty. Quality checks had identified improvements, but these had not been completed promptly.
The overall rating was Requires Improvement. Caring was rated Good. Safe, Effective, Responsive and Well-led were each rated Requires Improvement. This was the first overall rating at this level. At the November 2015 inspection, Safe had also been rated Requires Improvement.
Kind and respectful staff
People described staff as kind. Inspectors saw staff respond sensitively when someone was distressed and respect people's privacy and choices.
“People told us the staff were kind to them.” from the report
Support with ordinary life
People were supported to follow their interests, attend college and activities, visit cafes and take part in community and religious groups.
“People were supported to follow their interests and take part in activities that were socially and culturally relevant and appropriate to them, including in the wider community.” from the report
Staff knowledge and training
Staff had training relevant to the people living in the home and understood people's day-to-day needs and risks.
“The staff were knowledgeable about the risks to the individuals and the actions needed to reduce the risk.” from the report
People's views were gathered
The home used picture and word questionnaires to gather people's views about meals, activities, staff and important relationships.
“Your Views" questionnaires were in picture and word formats and were used by keyworkers to gain people's feedback on meals, activities and about people that mattered to them.” from the report
Outdated risk information
seriousRisk assessments had not been properly updated since the previous inspection. Some did not explain clearly how staff should reduce risks, including risks linked to mobility, seizures and equipment.
“However records were not up to date or accurate.” from the report
Incomplete medicine guidance
seriousInstructions for medicines given when needed did not always explain the signs and symptoms staff should look for or when to offer the medicine. This could lead to inconsistent decisions.
“The symptoms to look out for and when to offer the medicine were not detailed in the protocol and this meant there could be inconsistencies in when staff administered medicines.” from the report
Consent and liberty safeguards
seriousMental capacity assessments were missing for some complex care decisions. Applications to restrict people's liberty had been made before the required assessments and best-interest decisions.
“Despite the registered manager making authorisation requests to the local authority, to deprive people of their liberty, mental capacity assessments were not undertaken.” from the report
Care plans were not person-centred
needs fixingCare plans did not consistently include people's likes, dislikes, preferences or life stories. Some wording about personal care did not protect a person's dignity.
“People's preferences, their likes and dislikes were not part of their care plans.” from the report
Weak quality checks
needs fixingThe home had quality systems, but improvements were not prioritised or completed in good time. Incident information was filed but not reviewed as an overall pattern.
“Quality assurance arrangements were not always applied consistently.” from the report
- 01Which risk assessments have been updated since this inspection, and how do they now explain the support each person needs?
- 02How do you make sure as-needed medicine protocols explain when medicines should be offered and what signs staff should look for?
- 03Have mental capacity assessments and best-interest decisions been completed for every complex care decision and liberty restriction?
- 04How have care plans been rewritten to include each person's preferences, communication needs and life story?
- 05How do managers now review incidents and track whether agreed improvements are completed?
This was an unannounced comprehensive inspection covering all five key questions and the care provided to all three people living in the home. This explanation was written from the published report of 26 April 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 56 Sycamore Grove
3 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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