About the service: Sycamore Court is a residential care home, set over two floors that was providing personal care to older adults some of whom may be living with dementia. There were 27 people living at the service at the time of the inspection.

People’s experience of using this service:

People expressed mixed views about their experience of living at Sycamore Court. People told us they felt safe but they did not always feel listened to as feedback was not always acted upon. A very high turnover of managers and staff over the past four years meant that people did not always know who was in charge. Frequent changes in staffing and management meant that planned improvements did not always happen or were not sustained. This was summed up by one person who told us, “I’ve been here four years now, this place has the makings of paradise but [named manager] is hardly ever here, what this place lacks is continuity. The carers change too rapidly, what is the indication as to why they keep changing?”

Historically there had been high numbers of agency staff employed which resulted in a lack of continuity of care. However, recently there had been significant improvements in recruitment with the day shift now covered entirely by regular staff. At night some agency staff were still being used but at much lower numbers than previously. The improvements in staffing meant that the keyworker system had been re-introduced which would help people and staff get to know each other better and build positive relationships.

Safeguarding concerns had not always been raised and investigated appropriately and the information not always shared with the local authority or CQC.Similarly, accidents and incidents were not always followed through with the appropriate action to minimise the risk of re-occurrence. The service was working with the local authority to improve practice in this area.

Peoples medicines were not always managed safely and medicine audits had not been effective at picking up mistakes we found. Improvements to the environment and staff practices were required to support good infection control practices.

Risks to people were assessed though lacked detail. New systems for sharing information on risks to people had been introduced. Monitoring of food and fluid intake had improved but required further improvement.

There were gaps in staff training, supervisions and observations of staff practice. Plans were in place to make the required improvements. Mental capacity assessments and Deprivation of liberty safeguard applications were not always completed appropriately which meant some people were being deprived of their liberty unlawfully. Staff demonstrated an understanding of how to support people to make choices.

People had care plans but these did not always reflect an accurate picture of the person. The system for reviewing care plans was under review to ensure people were included in the process. People were assisted to have enough to eat and drink and said the food was good but the mealtime experience could be improved upon. Staff completed the required tasks but missed opportunities to engage with people.

People said staff were kind and caring but interactions between staff and people were generally task orientated with limited sustained interaction. There were limited opportunities for engagement and stimulation for people living with dementia.

There was a complaints procedure in place and people told us their concerns were dealt with positively. People and staff were positive about the new management team. The management team and provider were extremely open and transparent with us about the current failings of the service and were enthusiastic and committed to turning the service around. New systems and processes were being put in place to support the necessary improvements. However, it was too soon to comment on their effectiveness.

Rating at last inspection: Requires Improvement with breaches of regulations 9, 12,

We previously carried out an unannounced comprehensive inspection in February 2017 at which time the service was rated as requires improvement and three separate breaches of the legal requirements were found. These related to the safe management of risk, medicine management, unsafe environment, ineffective systems and processes to monitor quality and safety and insufficient staffing levels. Other areas that required improvement included training and support for staff, compliance with DoLS legislation, treating people with dignity and respect, keeping people’s confidential information secure, seeking feedback from people and improving activities and social interaction for people and ensuring a ‘dementia-friendly’ environment.

Following that inspection the provider sent us an action plan, which set out what they would do to meet the legal requirements in relation to the breaches and to improve the service.

We re-inspected the service in October 2017 to check that the necessary improvements had been made. At this inspection we found that whilst there had been some improvement in certain areas, there were still issues of concern and continued breaches of the regulations and the rating remains ‘Requires Improvement’.

This inspection took place on 29 and 30 October 2017 and was unannounced. During the inspection we found breaches of Regulation 9, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result of our concerns we sent the provider an urgent action letter asking them to submit an action plan to set out how they would deal with the issues we found. We then completed a further inspection visit on 22 November 2017 to check their progress.

Sycamore Court is a residential care home registered to provide care and accommodation for 39 older people. There were 35 people living in the service at the time of our inspection. The service was spread across two floors. Upstairs accommodated people with more complex needs related to living with dementia.

There had been a significantly high turnover of managers over several years and this had impacted on the quality, safety and effectiveness of the service. Instability in terms of leadership and a lack of oversight by the provider meant that many of the issues we found during our previous inspection had still not been addressed. There were quality assurance mechanisms in place to measure and improve the quality and safety of the service but these had been ineffective as they had failed to address many of the issues we found.

At our previous inspection a new manager had only recently been appointed and was going through the registration process. However before the process was completed they resigned from the company. We were subsequently notified that the provider had recruited a new manager who has since become registered. 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 new registered manager had a positive impact on the service and was viewed by people and staff as approachable, accessible and supportive. The registered manager took a ‘hands-on’ approach and any concerns or complaints were listened to and dealt with appropriately. However, due to insufficient support from the provider the registered manager lacked the resources to make all of the required improvements.

The service was struggling to recruit new staff so was using a high percentage of agency staff. This impacted on staffing numbers, deployment of staff and skill mix and meant that people’s needs were not always met safely and effectively in a way that reflected their preferences. People’s experience of being cared for varied considerably depending on which staff was providing the ca

This inspection took place on 15 February 2017 and was unannounced. During the inspection we found breaches of regulation 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the full version of the report.

Sycamore Court is a residential care home registered to provide care and accommodation for 39 older people. There were 34 people living in the service at the time of our inspection. The service was spread across two separate units. The ground floor unit supported people with mainly physical health needs and mobility difficulties, some of whom received their care in bed and many required the support of two care workers. The first floor accommodated people who were living with dementia.

The last inspection took place in February 2015 at which time the service was rated good in all areas. At that inspection a new manager had just been appointed and was going through the registration process. 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.

Since the previous inspection two further managers had been appointed. At the time of this inspection we were advised that the latest manager had withdrawn their application for registration and had given notice so the service was once again recruiting for a new registered manager.

We found that the high turnover of managers had resulted in a lack of stable and consistent leadership which was compounded by a lack of provider oversight of the service. This had impacted on the systems and processes necessary to monitor, assess and improve the quality and safety of the service.

Quality assurance checks and audits had been sporadic and were not as robust as they should be. The provider had not recognised the issues we identified during our inspection and had not always identified and taken action where people were placed at risk of harm or where their health and wellbeing was compromised.

There was a lack of mechanisms in place to include people and their relatives in the running of the service and request their feedback to drive improvements.

We looked at how medicines were managed by the service and found good practice guidelines were not consistently followed which posed a risk to people’s safety.

There were systems in place to assess, manage and review risks to people however these were patchy and inconsistent and sometimes lacked detail. Recording of information around risk also required improvement as it was not easy to find the most up to date guidance to keep people safe.

We looked at the staffing levels and found there were not enough staff to meet people’s needs safely and in a way that protected their rights and maintained their dignity. We observed people having to wait to have their needs met. Oversight in communal and private areas to assist people was cursory and inconsistent and placed people at risk of harm.

During the inspection visit we walked around the home to assess the standards of cleanliness and found some areas of the premises were not free from odours and that disposal of waste products was not always appropriate. We have since had assurances from the provider that the necessary action has been taken to address these issues.

Safety checks were carried out but some areas of the home were potentially unsafe to people living with dementia. We highlighted the risks we had identified and the provider has since advised us that the environment has now been made safe for people.

People were supported to see, when needed, health care professionals. Care staff recognised changes to people's physical and emotional well-being and knew how to share this information and reque

As part of our inspection on 9 May 2014, we looked at the care records of six of the 35 people living in Sycamore Court. We spoke with six people who used the service, three visitors who were their friends or relatives and a visiting health professional. We also spoke with five members of staff.

We looked at staff training records, health and safety checks, staff and resident meeting minutes and records of the checks the provider’s representative completed to monitor the quality of the service. We saw that the provider’s representative had visited the service to support the acting manager to lead the service in the absence of a registered manager.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service we saw a sign on the door that politely asked visitors not to allow people in or out of the service unless they knew them and it was safe to do so. This showed that reasonable steps were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service and that there were regular staff that they knew and who knew them. They also told us that they would feel able to speak up if they had concerns or worries and felt that they would be listened to. One person who used the service said, “They definitely ask if it is okay to do things for you. They could take advantage of us quite easily I suppose, but I cannot recall any event where that happened”.

We saw that staff were provided with training in safeguarding vulnerable adults from abuse. This meant that staff were provided with the information that they needed to recognise the signs of abuse and how to respond when they suspected abuse had taken place. Training for staff Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) was planned.

We saw records which showed that health and safety checks in the service were regularly performed to ensure the environment was safe for people to use. We found that people were cared for in a clean environment and they were protected from the risk of infection because appropriate guidance had been followed.

Is the service effective?

Overall, people's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The care records were regularly reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met safely and effectively.

People told us that they received the care they needed. One person said, “They look after me very well. If I want something I seem to get it”.

Is the service caring?

People told us that staff were caring. One person said, “The staff are lovely, very caring when they give me a bath and always ask me if they can do things”. Another person said, “Staff are wonderful, they have a laugh with us, and are kind”.

We observed that staff were kind to people they supported and interacted with people in a caring and professional way. We noted that staff addressed people by name and took time to talk to them and reassure them if they seemed worried or unsure. One person who used the service said, “If I need help I can ring my buzzer. This place is lovely and the staff are an exceptionally nice crowd.”

Another person who used the service said, “I love it here. The main thing is the staff, who are excellent without exception. They are helpful, obliging and considerate and do their jobs with a smile”. Visitors told us that they always found the staff to be welcoming, friendly and caring.

Is the service responsive?

People's care records showed that where concerns about an individual’s wellbeing had been identified, staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, such as doctors and district nurses.

People who used the service were provided with the opportunity to participate in a range of activities that interested them. People's choices were taken in to account and listened to. We noted that people were offered choices throughout the day, such as whether they would like to have tea or coffee or where to spend their time.

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service well-led?

The provider had recently notified us, as required, that the registered manager was no longer working in the service and we received the application to formally confirm this. The provider also told us of the arrangements they had put in place to support the deputy manager to oversee the service while a manager was recruited. Staff told us that they were able to speak to the acting manager when they needed to and that the acting manager was accessible and supportive to the team.

The provider had a quality monitoring process in place to support the acting manager to check the quality of the service. This was used to manage risks and to assure the health, welfare and safety of people who received care at the service. Records showed us that some areas were not checked and actions were not always taken promptly where issues were identified.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make in relation to line management support and guidance.

People we spoke with told us they felt well cared for. One person said, “They do care for me well. The staff are pretty good and answer the buzzer quickly. I prefer to stay in my room and watch television and read the paper. I use the hairdresser and get my nails done but I prefer not to join in with the other activities.”

We saw that care was planned and that staff were aware of the support that people needed. Relatives spoke positively about the home and the care provided to people living there. A visiting health professional also spoke positively about the care provided and the competency and caring nature of the staff team.

People told us that they enjoyed the food served and were offered choices. We found some lack of clarity as to whether all of the people using the service were offered food during the evening. The provider’s representative dealt with this during the inspection, instructing staff to ensure that everyone was offered a range of sandwiches and snacks every evening.

We found that medicines were managed to ensure people’s safety and well being. People had the equipment needed to support their safety and independence. The provider had a clear complaints procedure available. People told us they would feel able to raise any concerns with the staff.

People we spoke with who were able to express their views verbally told us they felt well cared for at the home. Comments included, “I am quite happy here” and, “I like it here and the activities are great.” They told us they felt comfortable about making everyday decisions and choices and that staff listened to these. People also told us that there were enough staff available to them when they were needed.

We were unable to communicate with some people and gather information as a result of their poor cognitive ability. We spent time in various areas around the home directly observing care to help us to determine what it was like for people living there. We saw that staff interactions with people who live at the home were positive. Staff were noted to listen effectively and to respond appropriately to people's communications.

People with whom we were able to communicate told us that they felt that they, or their relative, were safe at the home and that they would feel able to tell someone if they had any concerns or worries. One person said, "I haven't come across any concerns but would tell somebody if I did. I find all the staff charming."

A visitor told us that they were satisfied with the care their relative received at the home. They said, "I can't fault it, as mum would say; it is spot on. You can come at any time and always find it the same. [X] is like a different person since she has been here, her health is much better and she is putting on weight."

This inspection took place on 20 and 22 January 2015.

Sycamore Court is registered to provide care and accommodation for 39 older people. There were 35 people living in the service at the time of our inspection, some of whom had dementia related needs.

The last inspection of Sycamore Court took place on 9 May 2014 during which we found the provider was not meeting the requirements of the law in relation to assessing and monitoring the quality of the service provision. At this inspection on 20 and 22 January 2015 we found that the required actions had been taken and the provider was meeting legal requirements.

A manager had been appointed since the last inspection and had made application to the Commission to be registered as required. 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.

People were cared for by staff that been recruited appropriately and employed after appropriate checks were completed. There were enough staff available to support people safely and in the way they needed. Their medicines were kept safe and administered in line with the prescriber’s instructions.

People were supported by staff who knew them well and who had the necessary skills to support them appropriately. Care records were personalised and provided staff with guidance on how to meet people’s individual needs. People enjoyed a choice of meals and drinks and were supported to access healthcare services when they needed to. Staff had a good understanding with regards to people’s safety and welfare and to protecting their rights.

People, their relatives and visiting professionals were positive about the staff. We were told that they were kind, caring and responsive. Our observations of staff and discussion with them supported their comments. People were treated with dignity and respect and supported to maintain their independence.

An effective system was in place to regularly assess and monitor the quality of the service provided. The manager was able to demonstrate how they measured and checked the care provided to people who used the service and how this ensured that the service was operating safely. People felt able to express their views and they were listened to and acted upon to improve the service people received.