Sylvan House Residential Home

At the time of our inspection there were 13 people using the service. This was an unannounced, responsive assessment, prompted by concerns reported to the Care Quality Commission in relation to a recent quality assurance audit by the local authority. During the assessment we looked at 2 key questions. At the last inspection the rating was requires improvement, at this assessment the rating remains requires improvement.

We identified 2 breaches of the legal regulations in relation to staffing and good governance.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

Governance systems and audits were not effective in identifying or addressing areas for learning and improvement. Safeguarding concerns had been identified and action taken to mitigate future risk. The provider, however, had not reported some of these incidents to the local authority and had failed to notify CQC. The manager recognised this was an oversight and notifications were submitted retrospectively. Fire safety concerns had not been identified by the provider and environmental concerns were slow to be rectified. Staff had not received all the appropriate training to meet the current needs of people. Some medication instructions had not been updated onto the provider's system; however, people’s medicines were stored safely. The provider was open to feedback and had already started to address the concerns raised.

We observed there were sufficient staffing levels within the service and staff were recruited safely. People were treated with kindness, empathy and compassion. Feedback from people and relatives corroborated this and was positive. We observed frequent warm interactions with people, and staff treated people with dignity and respect. Staff knew people well. The provider worked collaboratively with other health professionals to support people. Health professionals confirmed referrals were made in a timely manner.

We have asked the provider for an action plan in response to the concerns found at this assessment.