CQC report explained · a residential care home
What the CQC found at Sylvan House Residential 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, March 2023
Requires Improvement; inspectors found people felt safe and well supported, but risks in care plans, fire safety and infection control were not always managed properly.
This was an unannounced follow-up inspection on 02 February 2023. Two inspectors and an Expert by Experience spoke with people living in the home, relatives, the manager and staff. They reviewed care records, medicines records, recruitment files and quality checks.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found enough staff, safe recruitment, safe medicines arrangements for most staff, and people who said they felt safe and received the help they needed.
However, some care plans gave conflicting or incomplete information about people's needs. Required safety checks were missed, and some fire doors did not close properly or were wedged open. Infection control and cleaning records also needed improvement.
Some progress had been made since the previous inspection. The previous breach about governance had been removed, and Well-led improved from Inadequate to Requires Improvement. The breach about safe care and treatment remained, so the provider must send an action plan and will be monitored.
Enough staff
Inspectors found adequate staffing levels and appropriate recruitment checks. People and relatives said staff responded promptly to call bells.
“There were adequate numbers of staff on duty at the time of the inspection, and rotas showed these numbers were regularly maintained.” from the report
Medicines usually managed safely
Medicines were stored securely and administered safely by trained day staff. Most staff had completed competency checks.
“Medicines were administered safely. They were stored securely, and the temperature of the room was monitored and within the recommended range.” from the report
People felt safe
People and relatives told inspectors they felt safe and believed staff knew people's needs.
“People told us they felt safe living in Sylvan House.” from the report
Inaccurate or incomplete care plans
seriousSome care plans conflicted with risk assessments or did not contain enough information about health needs. This could mean staff did not know how to support someone safely.
“Care plans contained some inconsistent information regarding people's needs, leaving them at risk of their needs not being met correctly.” from the report
Fire and building safety checks
seriousSome required internal checks had not been completed on time. Inspectors found fire doors that did not close properly or were wedged open, as well as unlocked window restrictors.
“We observed risks in the environment, such as fire doors that did not close or were wedged open and window restrictors that were not locked.” from the report
Governance did not find all problems
needs fixingNew quality monitoring systems were in place, but they did not identify issues with fire safety and care plans. Some actions had also not been completed promptly.
“New systems had been implemented to help monitor the quality and safety of the service, however these systems required some further work.” from the report
Infection control and cleanliness
needs fixingCleaning records were not completed robustly, and inspectors saw dirty chairs, chipped wood and other areas needing work. Some actions from an infection control audit were still outstanding.
“We saw bathrooms with no toilet roll holders, visibly dirty chairs which the manager told us were due to be replaced, ripped wallpaper and chipped wood around the home.” from the report
Night staff medicines checks
needs fixingSome newly recruited night staff had not completed competency checks for administering medicines. An on-call arrangement was being used, but this could cause a short delay.
“The manager had an on-call system in place to ensure people did not go without any additional medicines required at night.” from the report
- 01Have all care plans and risk assessments been checked so they give consistent information, including for nutrition and diabetes?
- 02Have all fire doors, fire exits, emergency lights and window restrictors been checked and any problems fixed?
- 03Have all newly recruited night staff completed their medicines competency assessments?
- 04Which infection control actions from the local authority audit and the home's own cleaning checks are still outstanding?
- 05How will the manager make sure the new quality monitoring systems identify and resolve problems promptly?
This was an unannounced focused follow-up inspection of Safe and Well-led, including infection prevention and control; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 March 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, March 2022
Sylvan House Residential Home is rated Requires Improvement; inspectors found gaps in risk and infection checks, inadequate oversight and a warning notice.
This was an unannounced focused inspection on 10 and 19 January 2022. Inspectors looked only at Safe and Well-led because of concerns about infection control, staffing, safe care and governance. They spoke with people, relatives, staff and professionals, and checked care, medicines, recruitment and management records.
The home was not always safe. Some risk assessments, care records, repositioning and nutrition records, fire checks and call alarm checks were incomplete or out of date. Infection control checks were also not always followed, including visitor screening and cleaning records. Staffing shortages led to care staff being used for domestic and kitchen work, with many agency staff covering shifts.
The biggest concern was management oversight. Regular audits and checks were not being completed, so risks and poor practice were not reliably found or fixed. The home breached regulations on safe care and treatment and good governance. Its overall rating fell from Good in July 2019 to Requires Improvement.
Medicines
Medicines were generally administered as prescribed. Controlled drugs, medicine temperatures and as-needed medicine arrangements were being managed safely.
“Medication administration records (MARs) contained all medications that should have been administered and MAR stock balance checks were accurate.” from the report
Protective equipment
Staff were seen using appropriate protective equipment, and supplies were well managed.
“Staff were observed wearing the appropriate PPE and PPE stock levels were well managed.” from the report
People felt safe
People and relatives told inspectors that people felt safe and received safe care.
“All five relatives expressed that they felt their loved ones received safe care.” from the report
External support
The home worked with outside health and care professionals, including community and district nurses and local GPs.
“The home worked in partnership with other external agencies and professionals.” from the report
Out-of-date risk records
seriousSome care records and risk assessments were not current. Important monitoring charts were also not always completed, increasing the risk that changing needs would be missed.
“Care records did not contain the most up to date information and risks was not effectively monitored or assessed.” from the report
Infection control gaps
seriousVisitors and professionals were not routinely screened as required, cleaning records were incomplete and there was no evidence of the required lateral flow testing programme for staff.
“COVID-19 screening arrangements were not complied with.” from the report
Staffing pressure
needs fixingSickness and vacancies affected staffing. Care staff were often moved to domestic and kitchen duties, while agency staff unfamiliar with the home were used frequently.
“Routine care staff were often allocated to domestic and kitchen duties and a high number of agency staff, who were often unfamiliar with the service were being utilised.” from the report
Poor management oversight
seriousCare, medicines, infection control and health and safety audits were not being completed. Records were often out of date, so managers could not show that problems were being identified and fixed.
“Inadequate governance and quality assurance measures meant that the quality and safety of care was not effectively assessed, monitored and risk was not always mitigated.” from the report
Limited involvement and feedback
needs fixingResident meetings and quality surveys did not take place, and there was no systematic process for handling complaints, views or suggestions.
“There was no systematic process in place to capture or respond to complaints, views or suggestions about the quality and safety of care.” from the report
Medicines storage and training
needs fixingTopical creams were not safely locked away in bedrooms, and competency assessments were incomplete for two staff members.
“Although oral medicines were appropriately stored, topical creams needed to be safely locked away in people's bedrooms.” from the report
- 01Have all care records and risk assessments been reviewed and updated, especially for falls, nutrition, repositioning and mental health needs?
- 02What evidence can you show that fire, call alarm, window restrictor and other safety checks are now completed on time?
- 03How are visitor COVID-19 screening, cleaning of frequently touched areas and staff testing being monitored?
- 04How many agency staff are currently being used, and how do you make sure they understand each person's care needs?
- 05What audits, resident meetings, surveys and complaints process are now in place following the warning notice?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 1 March 2022 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 Sylvan House Residential Home
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Sylvan House Residential Home →
- March 2022Requires improvementSafe: Requires improvementWell-led: Inadequate
Read what inspectors found at Sylvan House Residential Home →
- March 2021Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 2 February 2011.
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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