CQC report explained · a residential care home
What the CQC found at Sycamore Rise Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found caring and effective support, but serious weaknesses in medicines, risk management, infection control, recruitment and leadership.
This was an unannounced inspection on 27 and 29 March 2023. Inspectors spoke with people, relatives, staff and a visiting professional. They reviewed care and medicines records, staff files and management records, observed medicines being given, and looked around the home.
The home was rated Requires Improvement overall. Safe and well-led were both Requires Improvement. Inspectors found unsafe medicines records, gaps in risk assessments, environmental hazards, incomplete recruitment checks and weak infection control records. They also found staffing pressures and too much reliance on agency staff.
Effective, caring and responsive were rated Good. People generally said staff were kind, respectful and met their needs. Meals, healthcare support, personal choices, visitors and complaints arrangements were viewed positively, although activities were limited by staffing pressures and some care records needed updating.
The last rating was Good, published in October 2019. Activities had improved, but the provider had still not made enough progress in giving the registered manager formal support and maintaining oversight of the home. The provider said it had addressed some issues immediately after the inspection, and CQC requested an action plan and will monitor progress.
Kind and respectful care
People and relatives described staff as caring. Inspectors found that people were treated with dignity and respect and were encouraged to remain independent.
“People and families told us staff were caring.” from the report
Good staff training
Staff received regular training, supervision and competency checks in important areas such as moving and handling and safeguarding.
“Staff were receiving regular training and supervision. A training matrix was in place.” from the report
Meals and healthcare
People spoke positively about the food. The home monitored weights, made health referrals and worked with visiting health professionals.
“People provided positive feedback on meals.” from the report
People's choices and communication
People were involved in decisions about their routines and care. Communication needs were recorded so staff could understand how people expressed themselves.
“Peoples communication needs were being considered and care planned.” from the report
Some improvement in activities
An activities coordinator had been appointed and some activities and entertainment were taking place, although staffing shortages limited what was available.
“The provider had made some improvements.” from the report
Medicines records
seriousMedicine administration records had many gaps. Monitoring for one person's blood sugar was not recorded, cream applications were not consistently documented and medicine returns were not properly evidenced.
“Medication administration records were not fully completed and contained numerous gaps in recording.” from the report
Risks were not consistently assessed
seriousSome people did not have suitable risk assessments, including for choking and falls. Daily records did not always show that risks such as skin damage were being managed.
“Individual risk assessments were not always in place for health conditions.” from the report
Recruitment checks
seriousEmployment gaps and references were not always checked or recorded, and interview notes were sometimes missing. This could allow unsuitable staff to be employed.
“Recruitment checks were not being fully completed.” from the report
Infection control
seriousSome areas were not clean and were cluttered. Cleaning schedules had gaps, and audits had not identified the problems inspectors found.
“Infection prevention and control practices were not always safe.” from the report
Provider oversight
seriousThere was no formal evidence that the provider was supporting the registered manager or monitoring quality. Audits did not reliably find problems with medicines, infection control, care plans or daily records.
“Systems and processes were not always effective to oversee and manage the service.” from the report
Staffing pressure
needs fixingStaff shortages and sickness meant the home relied on agency staff. Staff said they sometimes had too little time with residents, and activities were limited.
“The rotas showed the service was using agency to try and cover staff shortfall.” from the report
- 01What has changed in the electronic medicines system, and how are medicine administration records now checked for gaps?
- 02Which risk assessments were missing or unclear, and how do managers now check that they reflect each person's current needs?
- 03How are cleaning schedules and infection control audits checked so that missed cleaning and clutter are identified quickly?
- 04What recruitment checks are now completed before staff start work, including employment gaps, interviews and references?
- 05How many agency staff are currently being used, and how does the home make sure staffing levels allow enough time for care and activities?
This inspection assessed all five key questions and included infection prevention and control; the report compares the findings with the previous inspection published in October 2019. This explanation was written from the published report of 13 May 2023 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, January 2021
Sycamore Rise Residential Care Home was not rated in this targeted inspection; its previous Good rating remained, and inspectors found good infection controls and enough staff.
The visit took place on 12 January 2021 and was announced with 24 hours' notice because of COVID-19 restrictions. It was a targeted inspection following a remote assessment, focusing on infection prevention and control and specific parts of Safe.
Inspectors found that staff understood and followed infection control procedures. Staff used suitable PPE, took part in weekly testing and had enough PPE available. The home was clean in the areas seen, and there were enough staff on duty to meet people's needs.
The inspection was not rated. The previous overall rating was Good, published in October 2018, and the report says this rating remained unchanged. The other parts of the service were not fully assessed during this visit.
Infection control
Staff had infection control training, used PPE appropriately and took part in regular testing. The home had sufficient PPE supplies and suitable arrangements for visitors during restrictions.
“All staff were observed to be wearing appropriate PPE during our visit.” from the report
Staffing and risk management
Inspectors saw enough staff on duty and found that risks to people's health, safety and wellbeing were assessed and managed.
“We observed there were enough staff on duty during the inspection.” from the report
Home improvements
The home had made several improvements since previous inspections, including a new roof and two new passenger lifts. Safety certificates were complete and up to date.
“Since the last inspections, several improvements had been made to the premises, including a new roof and two new passenger lifts.” from the report
Calm and attentive care
The home was described as calm, warm and peaceful. Staff responded promptly and were attentive to people's needs.
“The home was warm, comfortable and peaceful, and staff were observed to be attentive to people's needs.” from the report
Manager registration
needs fixingThere was no manager registered with the CQC at the time of the inspection. The manager had begun the registration process and intended to submit an application.
“The service did not have a manager registered with the Care Quality Commission.” from the report
Recruitment health checks
minorThe manager agreed to add a health questionnaire for future applicants. This was a planned improvement rather than a finding that current staff were unsuitable.
“The manager agreed to introduce a health questionnaire for all future applicants.” from the report
Recording lessons from incidents
minorThe manager reviewed accidents and incidents each month and discussed lessons with staff. They intended to improve the records of these discussions at handovers and staff meetings.
“She discussed lessons learned with the staff and intended to develop this further by recording the information as part of handover and general staff meetings.” from the report
- 01Has the manager's application for CQC registration now been submitted and completed?
- 02How are discussions about lessons from accidents and incidents now recorded at handovers and staff meetings?
- 03Has the health questionnaire been added to the recruitment process for all future applicants?
- 04How often are infection control procedures, PPE supplies and staff testing arrangements reviewed?
- 05What progress has been made with the ongoing refurbishment programme?
This was a targeted inspection of infection prevention and control and specific parts of Safe; it did not assess the whole Safe question or the other four key questions, and the previous ratings carried over. This explanation was written from the published report of 26 January 2021 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 Sycamore Rise Residential Care Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Sycamore Rise Residential Care Home →
- January 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Sycamore Rise Residential Care Home →
- October 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 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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