This unannounced inspection took place on 3 and 9 May 2018. Sylvan House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home accommodates up to 20 people in adapted premises. It does not provide nursing care.

During our last inspection of the home on 24 February 2017 we found a breach of Regulation 12 of the Health and Social Care Act Act 2008 Regulated Activities Regulations 2014 because medication was not always managed safely. We also found a breach of Regulation 17 of the Health and Social Care Act 2008 Regulated Activities Regulations 2014 because there was no effective auditing system in place to drive service improvements.

During this inspection we found that improvements had been made to the management of medication and that regular audits were carried out to monitor the quality of the service. However, we found a breach of the Care Quality Commission (Registration) Regulations 2009: Regulations 16 and 18 because the provider had failed to notify CQC of deaths and other occurrences at the home.

The home had a registered manager. 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 was not present during the inspection but the deputy manager and the provider were able to supply the information we required.

There were 13 people living at Sylvan House when we visited. There were enough staff on duty to ensure that people’s needs could be met. Robust recruitment procedures had been followed when recruiting a new member of staff to ensure they were of good character.

All parts of the premises looked clean and there were no unpleasant smells. Maintenance records showed that regular checks of services and equipment were carried out by the home’s maintenance person, and testing, servicing and maintenance of utilities and equipment was carried out as required by external contractors. A programme of upgrading the premises was on-going, however there were areas where prompt action was needed for example in the kitchen and laundry.

Risk assessments were recorded in people’s care notes and plans put in place to reduce the risks. These were reviewed regularly and kept up to date.

The manager had made DoLS applications to the local authority some while ago but none had been authorised. The deputy manager told us that this was being revisited and new applications were going to be made. We recommend that this is done without delay to ensure that people have the protection they require.

People had a choice of meals and malnutrition risk assessments were completed monthly. People at risk were referred to a dietician.

A programme of staff training was in place but not all staff had completed the training.

People who lived at the home told us that the staff provided them with good care and support. We observed that staff were aware of people’s individual needs and provided person-centred care.

People’s personal information was kept securely

We saw information in the care plans about people’s likes and dislikes. The care files we looked at showed that people had access to health professionals as needed. The care plans were written in a person-centred style and were kept up to date.

Regular meetings were held for staff and for people living at the home.

This inspection took place on 24 February 2017 and was unannounced.

This service was last inspected in April 2015. During this inspection we identified a breach of regulation in relation to assessing people’s capacity to consent to care and treatment. This was because information in people’s care plans relating to the Mental Capacity Act (MCA) was poor quality. The ‘effective’ domain of our report was rated as ‘requires improvement.’ Following this inspection the provider wrote to us to tell us what action they were going to take to ensure this breach was met. We checked this as part of this inspection.

During this inspection we found that some improvements had been made and people living at the home had had their capacity re-assessed for individual decisions and applications to the local authority had been made when needed. However, the capacity assessment was not part of the person’s care plan. When we queried this, we were told that the service had asked people’s psychiatrists to complete the capacity assessments and the service had not been given a copy for their records. The deputy manager had printed of templates of capacity assessments as they had identified this was a problem, and were in the process of completing their own assessments on people.

We saw that the registered manager and the staff team had familiarised themselves with the Mental Capacity Act (MCA) 2005 by attending additional training. The MCA is the legislation that underpins mental capacity and how it is applied in care settings. The provider had improved enough to not be in breach of this regulation, however we have made an recommendation for further good practice .

We identified other areas of concern during this inspection which resulted in two breaches of Regulations in relation to medications and the governance of the home.

A registered manager was in post. 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.

Medication was not always being administered correctly or safely. We observed some poor practice with regards to medication administration, and we saw that medication was not always being stored in the correct packaging. We identified a breach of regulation in relation to this.

The general oversight of the registered manager required improving. There had been very little in the way of auditing since our last inspection in April 2015.

Some audits were taking place in areas such as medication and care planning, however there was a lack of auditing in areas such as infection control, and staff records, such as supervision. The medication audits staff completed, were not completed on a specific day of the month and often five or six weeks would lapse between audits. There were some months missing.

Some of the areas of the home were not clean. The registered manager had however, completed an infection control audit a few days prior to our inspection and had identified some of these areas of concern. Prior to this audit, there had been no other infection control audits taking place, and there was no documented process for deep cleaning in the home. We identified a breach of regulations in relation to the governance of the home.

Supervision records were not as up to date as they should have been, some supervisions had taken place in July for half of the staff, and the registered manager had a schedule in place to ensure all other staff would be supervised in the next few weeks.

There was a process in place to ensure staff were suitably recruited to enable them to work with vulnerable people. This included a police check, (referred to as a DBS) which standards for disclosing and baring service. Two verified references for staff, and proof of identificati

During the inspection we set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People said they felt safe and risk assessments were carried out to identify and manage risks to people who used the service, such as falls, pressure ulcers and malnutrition.

The manager and deputy manager were aware of the Mental Capacity Act and Deprivation of Liberty Safeguards, although no applications had needed to be submitted. This meant that people would be safeguarded if they did not have capacity to make certain decisions.

The home was clean and there were appropriate arrangements in place for laundry and maintaining water safety.

Is the service effective?

Staff were trained and supported to meet the needs of people who used the service. People who lived at the home told us they were confident in the skills and experience of the staff who cared for them. One person said "The carers are very good and the manager is brilliant". A visitor said "It seems a very nice home, the staff are very good and they are always welcoming".

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. One person commented: "I've been here for many years and the care is very good. I like playing bingo and joining in the sing-songs. If I'm not well they always get the doctor straight away".

Is the service responsive?

People’s health and care needs were assessed with them, and they were involved in writing their care plans. People’s preferences, interests, aspirations and diverse needs were recorded and reviewed and support was provided in accordance with people’s wishes. One person said: "I'm quite happy. I mostly look after myself but the staff help me with the things I can't do. I like to bet on the horses and they take me out to the shops and the bookies most days".

Is the service well-led?

People who used the service said that the manager regularly asked them if they were happy with the service. We saw that the home had satisfaction surveys they could send to people who used the service, relatives and visiting professionals, but none had been sent out since 2012. This meant that the provider did not have an effective system in place to regularly assess and monitor the quality of the service.

Some areas of the home were badly maintained, particularly bathroom facilities, downstairs corridors and the exterior of the premises and grounds. The manager had identified the areas that required improvement and a new shower was being installed on the first floor, but improvements were taking too long, which was having an impact on the people who used the service because some toilets were inaccessible and they could not sit outside in the nice weather.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to maintaining the premises and quality assurance.

We spoke to five people who lived at the home about consent and all were happy they could make their own decisions. This meant that people were asked to give their consent before they received support. Comments included :

"Staff always ask me before they do anything."; and

"I'm not forced to do anything I don't want to."

We asked the people we spoke with if they felt comfortable, safe and well cared for. They told us :

"Staff are wonderful, I have been here for a long time and so have most of them.";

"Oh yes, those who need it are well looked after. I do most things myself, but the girls will get shopping if I need it;"

Staff we spoke with said they knew what people liked to eat and what they did not like. Cupboards were well stocked with full fat milk, butter, cream, cheese, eggs and fruit and vegetables. People were consulted weekly about menus which meant they received food they liked and ensured their dietary requirements were met.

We looked at the environment and saw that redecoration work such as replacement wallpaper, paint to woodwork and some new flooring was being undertaken, with plans for further changes. We found the environment to be safe. Staff spoken with said they were happy at work and felt well supported in their role. There was an "open door" culture which meant staff could approach management whenever they needed to. Training was provided appropriate to roles and information about people was recorded and stored appropriately.

People who used the service told us they were happy living at the home, were well cared for and treated with dignity and respect. They told us:

“It’s very good here”,

“We are very well treated”.

People told us they were involved in their care and treatment and were able to make choices in every day living activities such as food choices and level of assistance needed with personal care.

We observed that people were well cared for and treated with dignity and respect. People’s needs were assessed, planned and reviewed. We found that the provider monitored and had a complaints process in place and gained views on the service from staff and people who used the service.

Staffing levels were appropriate and safe. Staff were experienced and knowledgeable in the people they were caring for. Staff also demonstrated an awareness and understanding of how to protect people from abuse.

People told us that they were more than satisfied by the care in the home, one relative told us that said that the care given to her husband was “exceptional”.

One person living in the home told us that it was a bit shabby in places but in her opinion that was unimportant as the most important thing was that she got good care and the care in the home was “excellent.”

People told us that the food in the home was good and that they enjoyed the food, one person told us that she was always given a choice of what she would like to eat.

People living in the home told us that staff help and support them to make doctors appointments and attend hospital appointments.

During our visit people told us that they felt that the staff always listened to them.

At our last inspection in June 2014, breaches of regulations were identified. We asked the provider to take appropriate action to ensure improvements were made. We undertook this comprehensive inspection on the 13 and 22 April 2015, this was an unannounced visit. During this inspection we found that the required improvements had been made however we found other areas of concern.

Sylvan House Residential Home is registered to provide accommodation to 20 people some of whom have dementia. There are 18 bedrooms, two bedrooms are shared. The home is a detached two storey building in Prenton, Wirral. A small car park is at the front of the home and there is a garden available within the grounds. The home has recently been refurbished throughout to an adequate standard. A lift enables access to the bedrooms located on the first floor for people with mobility issues. Communal bathrooms with specialised bathing facilities are available on each floor. On the ground floor, there is a communal lounge and a dining room for people to use.

The manager was registered with the Care Quality Commission. 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 and associated Regulations about how the service is run.

During this inspection, we found breaches of Regulations 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw that staff asked people’s consent before providing personal care and that people were able to choose how they lived their lives at the home. Some people who lived at the home had short term memory loss or dementia type conditions. Where people lacked capacity, care plans lacked adequate information on how consent was given and how this impacted on their day to day lives. We spoke to the manager and deputy manager about the Mental Capacity Act (MCA) 2005 and the associated Deprivation of Liberty Safeguards (DoLS) who said that they had not attended MCA and DoLS training and acknowledged that this was an area for development and required implementation for all staff.

Some people had lived at Sylvan House for a considerable time and considered it to be their home, others had moved in more recently. People who lived at the home were happy there and held the staff in high regard. They said they were well looked after. People who lived at the home were supported to maintain their independence and were treated with dignity and respect at all times.

The staffing levels were sufficient in all areas of the home at all times to support people and meet their needs and everyone we spoke with considered there were enough staff on duty.

The home needed to improve their system of recruiting new staff as they were not conducting checks on references as required. They did not have an induction programme in place that ensured staff were competent in the role they were doing at the home prior to working unsupervised. The training programme was not being implemented or maintained appropriately to ensure staff were competent in their roles. Staff were received supervision in their job role and there was an annual appraisal programme in place.

People were able to see their friends and families when they wanted and there were no restrictions. Visitors were seen to be welcomed by all staff throughout the inspection.

The eight staff we spoke with were able to tell us the action they would take to ensure that people were protected from abuse. All staff had received e-learning training about safeguarding. People told us they felt safe at the home and had no worries or concerns. There had been no safeguarding incidents reported by the manager in the last 12 months.

The home had the majority of medication supplied in monitored dosage packs from their local pharmacy. Records relating to these medications were accurate. All medication records were completely legibly and properly signed for. All staff giving out medication had been medication trained. The medication storage fridge was not storing medicine at the correct safe temperature on the first day of this inspection; it was in working order on day two. Staff were not recording the administration of PRN medication information accurately. The medication policy and procedure required updating.

Records we looked at showed that the required safety checks for gas, electric and fire safety were carried out. Equipment was properly serviced and maintained and in sufficient supply and the home had recently been awarded a five star rating (excellent) by the Environmental Health.

The six people we spoke with confirmed that they had choices in all aspects of daily living. Menus were flexible and alternatives were always provided for anyone who didn’t want to have the meal off the menu that was planned. People we spoke with said they had plenty to eat. The food we tasted was well presented and tasted good. There was however a lack of one to one activities provided.

The two care plans we looked at gave details of people’s medical history and medication, and information about the person’s life and their preferences. People were all registered with a local GP and records showed that people saw a GP, dentist, optician, and chiropodist as needed.

We were told by the manager that people were provided with information about the service when they initially moved into the home. Information in relation to how people were able to make a complaint was in the Service User Guide and displayed in the home. We discussed complaints with the manager and deputy manager and asked them to provide the complaints records and information. They were unable to as there was no complaints log for receiving complaints. People and relatives we spoke with however said they would know how to make a complaint. No-one we spoke with had any complaints.

There was quality assurance system in place to obtain people’s views. A satisfaction questionnaire had been sent out to gauge people’s ‘satisfaction’ with the service provided. The home received very positive feedback from the last survey collated in March 2015. The provider was implementing a new quality assurance system and the managers had not conducted audits for infection control audits, staff training, medication and accidents and incidents audits.

People and staff told us that the home was well led. Staff told us that they felt well supported in their roles. Everyone we spoke with thought the home was well led and all of the care staff said that they would not hesitate recommending the home to anyone.