What life is like for people using this service:

A new provider had taken over the service in the past 12 months and this had led to the registered manager and deputy manager implementing new systems around care planning, risk assessment and staffing. The staffing levels had reduced since this change because the tool the provider used to work out the number of staff needed did not consider the needs of people living with dementia or those with nursing needs. This change had had led to people having to wait for key areas of support such as meals, drinks and personal care. We discussed our observations with the provider and they immediately reacted to this and increased the staffing levels. They agreed to review the way they determined staffing and to ensure they checked their system worked.

The lack of resources had impacted on the time the registered manager and leaders had to ensure risks were managed well. For example, people’s hydration, nutrition and pressure area care monitoring. The records we viewed did not always reflect support had been given. Changes were made immediately and on day three of inspection better records were viewed and systems to monitor this were in place.

The provider had started to implement their own systems to check the safety and quality of the service and this had not picked up the staffing and record keeping issues we noted. They agreed to reflect and develop their systems further.

Although staff morale was low the main motivation of staff at all levels from the care workers to the registered manager and provider, was for the best interests of people to be maintained. We were confident the registered manager and provider understood their role in engaging with the whole staff team to listen and support them moving forwards.

People had good health care support from professionals. Where staff noted a concern they quickly involved healthcare professionals, this included support to manage people’s nutrition and pressure area care.

People received care and support based on their needs and preferences. Staff were aware of people’s life history and preferences and they used this information to develop positive relationships and deliver person centred care.

People told us they felt well cared for by staff who treated them with respect and dignity. People enjoyed the range of activities on offer but told us they felt bored at times. The provider quickly responded to this feedback and increased the number of days activities support was available. People were pleased with this.

More information is in Detailed Findings below

Rating at last inspection: Requires Improvement (report published 14 September 2017)

About the service: Sycamore Hall is a residential care home that provides personal and nursing care for up to 60 people, some of whom are living with dementia. At the time of the inspection 58 people lived in the service.

Why we inspected: This was a planned inspection based on the rating at the last inspection. We saw improvements had been made since our last inspection and that the impact of poor resourcing has meant the rating remained Requires Improvement. This is the third time this service has been rated Requires Improvement.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure the provider improves the rating of the service to at least Good. We will revisit the service in the future to check if improvements have been made.

We inspected Sycamore Hall on 9, 18, 19 and 31 July 2017. The first and second days of the inspection were unannounced and we told the provider we would be visiting on days three and four.

The service was last inspected in August 2016 and was rated requires improvement. We found the provider had breached six regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to staffing, including supervision and training of staff, person centred care, records not being stored confidentially, safe care and treatment, consent and governance. The provider had also failed to submit statutory notifications which we dealt with separately.

We saw improvements had been made in all areas at this inspection and the provider was no longer in breach of any regulations. Following the last inspection the provider had enlisted various internal resources to support the service to improve systems and process. This had included regional quality support that also provided clinical support for the nursing staff. The provider was still working when we inspected to embed improvements in some areas. Changes made had affected staff morale and had resulted in a turnover of staff. The manager continued to work hard to recruit and support the current staff team whilst encouraging positive change and ensuring staff understood their responsibilities. The provider was committed to making further improvements and we were confident this would happen.

Sycamore Hall is a large purpose built accommodation which can provide personal and nursing care for up to 62 older people, some of who maybe living with dementia. At the time of our visit 52 people lived at Sycamore Hall.

It is a condition of the provider’s registration that they have a registered manager in post. At the time of our visit a manager was in post and registered with us. 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 registered manager is referred to as ‘the manager’ throughout this report.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. Other quality assurance checks were made by the manager, senior team and provider to ensure safety and quality. Those checks had highlighted most of the areas for improvement which we note in this report. Where the systems did not highlight areas for improvement, such as staffing and recruitment the provider listened to our feedback and agreed to make changes.

Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed. Risk assessments had been personalised to each individual and covered areas such as moving and handling, choking, health and distressed behaviour. This enabled staff to have the guidance they needed to help people to remain safe. The way staff recorded details to monitor areas of risk such as fluid intake and food intake was not always robust. We saw improvements by day four of the inspection.

Systems had been put in place since the last inspection to improve the support and training staff received. We saw improvements had been made and senior staff were being supported in their role to continue to develop this area. Staff appraisals were booked to be carried out in 2017.

We saw there were not enough staff on shift during day one and two to meet people’s needs appropriately. The nominated individual ensured improvements were made by the end of this inspection. We were confident staffing levels wer

This was an unannounced inspection which took place on the 18 August 2016. The service was last inspected in December 2013 and was meeting the regulations in force at that time.

Sycamore Hall is a care home providing nursing and personal care for up to 62 people who are living with dementia. Sycamore Hall has a ground and first floor, with the first floor providing support for people who require nursing care. There were 56 people living there at time of inspection.

The service did not have a registered manager in post; the service had a registered manager who was no longer working at the service. A new manager had recently started working at the service and intended to register. 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 service also had a home manager who had day to day responsibility for running the service and staff supervision.

Staff had not identified and reported possible safeguarding alerts to the local authority and to us. We write to the provider to remind them of the need to notify us promptly of these events.

We found there were a number of potential hazards around the service which had not been identified or acted upon by staff. For example doors to chemical storage areas were unlocked and potential hazards had not been identified by staff and action taken to remove these.

Staff told us that at times they had little time to spend with people and were observed to be task focused. People were not always observed consistently throughout the service and staff seemed rushed at times.

Staff were recruited correctly and had been subject to checks before starting work with vulnerable people. People’s medicines were managed well by the service and we saw that staff had been trained and supported to maintain competency.

Staff had not consistently received supervision over the previous year due to changes in management. Staff told us they could not always access the training needed to meet their developmental needs and the requirements of people using the service. For example staff felt their understanding of the needs of people with a dementia related condition was limited. Some people’s needs for behaviour support were not responded to effectively by the service, staff told us they had limited training on supporting dementia related conditions. We saw the provider had drafted a proposal for the development of staff training and more personalised care for people using the service. Peoples care records were not always kept securely.

The service was not adhering to the principles of the Mental Capacity Act; records and assessments of capacity could not always evidence best practice in supporting people who lacked capacity. Consent was not always clearly gained from the person, or their representative, before care or treatment commenced.

The service had been recently re-decorated but it was not always suitable for the needs of people who had a dementia related condition and had made parts of the service stark and lacking in stimulation for people.

Staff did not always have sufficient time to interact with people except when receiving care. Some staff were task focused at times rather than focused on the person they were supporting. We observed some positive and negative interactions between people and staff. Staff told us they did not always get the support they needed to meet people’s needs. They told us the team felt stretched at times to meet people’s complex needs and they struggled to attend essential training.

Relatives and external professionals told us they found the staff to be caring towards people and told us the home was good at communicating with them as people’s needs changed.

Care plans were task focused and

We used a number of different methods to help us understand the experiences of people living at the home because some people were unable to talk to us. This included observing the delivery of care and speaking to visitors as well as people who lived at Sycamore Hall

We spoke with two people who lived at the home. We also spoke with five relatives who were visiting the home. Everyone told us they were satisfied with the care they or their relative received. People told us that they were treated with respect and were able to make choices and decisions about their care.

We saw from people's care plans that people were supported to live as independently as possible. Staff at the home had carried out an assessment of the needs of each person, and kept this under review, this helped make sure appropriate care and support was given.

People who lived at the home were protected from risks of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. The staff we spoke with had received training in safeguarding adults.

We reviewed the recruitment and selection processes for new staff and found them to be robust. This ensured that people were supported by suitably qualified, skilled and experienced staff.

The home had systems in place to make sure people were safely cared for. This included policies and procedures and quality monitoring systems.

We did not talk to people in detail about what it was like to live at Sycamore Hall. This visit concentrated on checking whether improvements had been made to the premises, such as the carpets on the first floor corridors in the home, as these areas had previously had an offensive odour. There were other aspects of cleanliness the service needed to improve such as there had been dust and dirt under some beds and dusty possessions in some people's rooms.

There was also stained and broken furniture in some bedrooms, and some soft furnishing in the lounges where the furniture covering had split. In one persons room we identified a lead from an air mattress that had been identified as a trip hazard.

We had seen that there were home made ‘baby- gate’ style door guards, one of which was made from garden trellising and the provider was asked to consider more appropriate methods and /or equipment and assisted technology to safeguard people.

However during our tour of the premises we also visited some of the lounges and dining rooms and saw that some people were sitting relaxed and contented or having their lunch, whilst others were walking around the home as they chose.

We observed the care of people, as people using the service were unable to give us their views due to their complex needs. Staff interacted with people in a pleasant, friendly manner and were able to engage people in activities. On the whole, people using the service were calm, relaxed and happy during our visit.

The home provided a sufficient choice of nutritious food and drink, and people were supported to eat where necessary. However, it was observed that staff did not always explain or offer a choice of food when serving.

We looked at the care plans for five people who live at the home. These showed that the home had carried out an assessment of each person’s needs of prior to admission. The assessments and care plans had been kept under review, to enable appropriate care and support to be given.

We spoke with five of the home’s care staff and the home manager. Mixed feedback was received from staff. Staff told us they thought the home provided sufficient care to people using the service. However, some staff said they felt unsupported by management and said that there was a lack of teamwork within the home.

There was a pervasive smell of urine throughout most of the first floor and some bedrooms had furniture in need of repair or replacement. This meant that people did not live in a pleasant and well maintained environment. We have asked the provider to take action to rectify this.

At the site visit people told us they were happy with the care and support they were receiving at the home.

Our inspection concentrated mainly on the first floor where people have nursing needs, where we were unable to speak with many of the people, so we observed how they interacted with the staff on the unit and talked with the relatives and friends who visited them.

We were able to observe staff treating people respectfully. People were seen to be comfortable to approach staff to make their needs known.

Relatives told us the home has “improved” and made extremely positive comments about the staff. They told us staff were "brilliant" and one explained how "85% of the staff appear to love the job" and this showed in how they treated people. They described the staff as always calm and helpful.

Relatives generally told us people’s health and care needs were met, we were told the care is “excellent” and one explained how their relatives overall health had improved since moving into Sycamore Hall. However we were also told “there are not always enough staff” on the nursing unit on the first floor , where people needed more help with their personal care and to engage them in daily life and activities.