CQC report explained · a residential care home
What the CQC found at Sydenham House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found gaps in risk assessments and records, medicines management, fire safety and environmental risk controls. People and relatives said they felt safe, and staff responded to concerns and supported people promptly during the visit.
- Effective?
- Good
- This question was not inspected during this focused inspection, so no new rating was given.
- Caring?
- Good
- This question was not inspected during this focused inspection, so no new rating was given. Feedback about staff was positive.
- Responsive?
- Good
- This question was not inspected during this focused inspection, so no new rating was given.
- Well-led?
- Requires improvement
- The provider did not have effective checks to monitor the quality and safety of the home. The management team was aware of the shortfalls and had begun considering improvements, but there was no clear action plan with priorities and timescales.
What inspectors found, December 2023
Sydenham House rated Requires Improvement; inspectors found risks in care records, medicines, the environment and quality checks.
This was an unannounced focused inspection on 16 October 2023. Two inspectors and an Expert by Experience observed care, checked the building, spoke with people and relatives, and reviewed care, medicines, staff and management records.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found that some risks were not fully assessed or recorded. These included nutrition, moving and handling, night-time support, fire safety, legionella and hazardous substances. Medicines systems and records were also not always safe.
The home had weaknesses in its checks on quality and safety, so some problems had not been identified by the provider. People and relatives said they felt safe, staffing appeared sufficient during the visit, and staff were caring. The rating changed from Good at the previous inspection in 2018 because of the findings in this focused inspection.
People felt safe
People and relatives told inspectors they felt safe in the home.
“People and their relatives told us they felt safe living at the service.” from the report
Staffing
People and relatives said there were enough staff. Inspectors saw people receiving support without undue delay.
“During the inspection, we observed people being supported in a timely manner.” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including the use of protective equipment and managing infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Positive relationships
Feedback about the atmosphere, staff and management was positive. The home worked with families and health and social care professionals.
“The service worked in partnership with people, their families, friends and community health and social care professionals to maintain people's health and well-being and to achieve positive outcomes for them.” from the report
Risk assessments
seriousSome people's risks were not fully recorded, including nutrition, moving and handling, emotional needs and night-time support. Environmental risks, including legionella, fire safety and hazardous substances, also needed better control.
“Effective systems had not been fully implemented to assess and mitigate risks to the health, safety and welfare of people using the service.” from the report
Medicines
seriousMedicines records were not always signed and checked correctly. There were also gaps in stock checks, as-required medicines guidance, homely remedies and medicines care plans.
“The provider did not always ensure that people's medicines were managed safely. This placed people at risk of harm.” from the report
Quality monitoring
seriousThe provider's audits had not identified important problems with risks, medicines, care records and environmental safety. There was no clear action plan with priorities and timescales.
“The provider did not operate effective systems to monitor and improve the safety and quality of the service.” from the report
Mental capacity records
needs fixingCare records did not always clearly show people's capacity for specific decisions. CQC recommended that the provider review how this was assessed and recorded.
“We recommended that the provider reviews their systems of assessing and documenting people's capacity related to specific decisions.” from the report
- 01What has been done to make sure every resident has up-to-date risk plans for nutrition, moving and handling and night-time support?
- 02How are medicines records, stock checks and as-required medicines now being audited?
- 03What action has been taken on legionella checks, fire safety records, window restrictors and night-time evacuation support?
- 04How will you monitor care records, staff training and equipment service dates, and when will these checks be completed?
- 05How are you recording whether each person has capacity to make specific care decisions?
This was a focused inspection of Safe and Well-led only; the other three question ratings were not inspected and the overall rating was calculated using the previous ratings. This explanation was written from the published report of 12 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2021
Inspected but not rated; inspectors found strong COVID-19 infection controls, but were not assured that outbreak staffing plans were robust enough.
This was an announced, targeted inspection on 19 January 2021. It looked at how the home was prepared to prevent and control coronavirus infection. The home was inspected but not rated, so this report does not give an overall quality rating.
Inspectors found that the home had safe visiting arrangements, including a visiting cabin, and supported contact by telephone and video calls. Relatives could visit safely when people were receiving end of life care.
The home tested people and staff, followed isolation guidance, used protective equipment and improved cleaning, laundry and waste arrangements. People were monitored for infection symptoms and supported with activities during the pandemic.
Inspectors were not assured that the home's plans for staffing during a coronavirus outbreak were robust enough. They signposted the provider to resources to improve this.
Safe visiting
The home had a visiting cabin and supported telephone and video contact. Relatives could also visit safely when end of life care was being provided.
“The provider had installed a 'visiting cabin' in the grounds in accordance with recognised safe visiting guidance.” from the report
Safe admissions
New people were admitted after a negative coronavirus test and were supported to self-isolate for 14 days.
“People were only admitted following a negative COVID-19 test.” from the report
Infection controls
Inspectors found that staff used protective equipment correctly and that cleaning, laundry and waste arrangements had been improved.
“Action had been taken to reduce the risk of an outbreak which included correct use of personal protective equipment (PPE).” from the report
Health monitoring
People were checked for symptoms and results were shared electronically with the GP, allowing prompt clinical support. People and staff had also been supported to receive vaccinations.
“People's health and wellbeing was monitored.” from the report
Outbreak staffing plans
needs fixingInspectors were not assured that the contingency plans would provide enough staff if there was a coronavirus outbreak. The provider was signposted to resources to develop its approach.
“We were not assured the provider's contingency plans were robust enough to staff the service in the event of a coronavirus outbreak.” from the report
- 01How were the contingency plans for staffing during a coronavirus outbreak changed after this inspection?
- 02How would visits be arranged if infection restrictions were needed, including visits at the end of life?
- 03How are new admissions tested and supported to self-isolate?
- 04How often are people and staff tested, and how are infection symptoms reported to the GP?
- 05How will activities and contact with relatives continue if there is an outbreak?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic, and the service was inspected but not rated overall. This explanation was written from the published report of 17 February 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Sydenham House
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- June 2018GoodSafe: GoodWell-led: Good
- May 2018
Registered with the Care Quality Commission on 17 May 2018.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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38 live-in carers within about an hour of Gloucestershire
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Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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