Date of inspection: 06 November 2025 to 19 November 2025. Sylvian Care Southampton is a domiciliary care agency and provides personal care to people living in their own homes. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. At the time of this inspection 27 people were receiving support with personal care. We inspected to check if improvements had been made following our last inspection. The provider was previously in breach of the legal regulations in relation to the safe use of medicines, failing to ensure safeguarding systems were effective and good governance. Improvements were found at this inspection and the provider was no longer in breach of these regulations. People were supported to have choice and control and were involved in planning their care. Staff assessed and mitigated risks and care plans guided safe practice. Medicines were mostly managed safely, although there was scope for clearer care planning and recording in relation to the application of creams. Governance systems had improved, and the provider was keen to learn and to continue to improve the service. Complaints were acted on, however some records for complaints needed to be more robust. Staff knew people well and received appropriate training and support. There were enough staff to meet people's needs. Staff were kind and caring and had a good understanding of how to meet people’s needs. There was a system in place to enable people to express any concerns or complaints they may have with senior staff.
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Sylvian Care Southampton received an overall rating of Requires Improvement at its first inspection, with regulatory breaches identified in medicines management (Regulation 12), safeguarding (Regulation 13), and governance/record-keeping (Regulation 17). The service demonstrated genuine strengths in caring and responsive practice, with consistently positive feedback from people and relatives, but governance systems failed to detect significant safety and recording failures.
Concerns (8)
criticalSafeguarding: “we identified three examples where information of concern had not been appropriately escalated and reported to the relevant local authority where this was legally required.”
criticalMedication management: “The provider failed to ensure medicines were safely managed where a person required their medicines to be administered covertly.”
criticalGovernance: “Quality assurance and governance systems in place were not always effective or robust...they did not identify the concerns we found at this inspection.”
moderateRecord keeping: “multiple examples where the provider had failed to ensure people's care records were contemporaneous, accurate and consistently up to date to reflect their current needs.”
moderateConsent / capacity: “assessments of people's capacity had not been undertaken or reviewed in line with requirements. This included decisions around peoples consent to their care and treatment and medicines support.”
moderateIncident learning: “the governance systems in place were not robust to ensure records were completed contemporaneously which meant an analysis of themes and trends could not be completed in a timely way.”
moderateCare planning: “several examples where information was conflicting or not always up to date across all relevant sections of peoples care plans.”
moderateStaff competency: “Staff had limited knowledge on their legal responsibilities to safeguard people...there was a lack of knowledge and understanding on when and how they could raise concerns.”
Strengths
· People and relatives consistently reported feeling safe and receiving kind, compassionate, dignified care from staff.
· Consistent staffing arrangements with people receiving care from familiar staff who knew their needs well.
· Person-centred care plans capturing personal history, preferences, routines and individual communication needs.
· Effective infection prevention and control practices including appropriate use of PPE.
· Staff were responsive to changes in people's health, promptly escalating concerns to healthcare professionals.
Quality-Statement breakdown (20)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity, and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood