CQC report explained · a residential care home
What the CQC found at Sydenham House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Sydenham House was rated Requires Improvement; inspectors found risks in medicines, staffing and management oversight, with warning notices issued.
This was an unannounced focused inspection on 31 October and 1 November 2022. Two inspectors and two Experts by Experience spoke with 16 people, 13 relatives and nine staff. They also observed care and checked care, medicines, staffing and management records.
Inspectors found significant concerns about medicines, risk assessments, staffing levels, staff training and supervision, mental capacity assessments, and the systems used to check safety. These problems placed people at increased risk of harm. The home was still in breach of regulations from the previous inspection.
There were also positive findings. People and relatives said they felt safe, staff were described as kind, the food was considered good, and infection control measures were generally followed. The overall rating remained Requires Improvement, and this was the home's second consecutive rating at this level.
People felt safe
People and relatives generally said they felt safe and supported, despite concerns about staff shortages.
“People and relatives told us people felt safe with the care and support they or their relative received.” from the report
Kind staff
People described staff as kind and caring. Inspectors also found that staff knew people and their needs.
“People told us they were supported by kind and caring staff.” from the report
Food and mealtimes
People had access to a balanced diet, with choices of food and drink. People and relatives were satisfied with the food.
“The mealtime experience we observed was pleasant, people were offered a choice of food and drink and interactions were positive.” from the report
Infection control
The home was clean and staff generally followed infection prevention measures. Some cleaning records and staff refresher training were incomplete.
“The service appeared clean and was well maintained.” from the report
Medicines and risks
seriousMedicines were not always given or recorded safely. Inspectors also found missing or incomplete risk assessments, including risks linked to choking, falls and a potentially flammable cream.
“People were at increased risk because medicines were not always managed in accordance with national guidance.” from the report
Staffing levels
seriousThe home was regularly operating below its required staffing level. People and relatives reported waiting for help, and staff said they were under pressure.
“There were not always enough available staff to meet people's needs safely.” from the report
Mental capacity decisions
seriousMental capacity assessments were not completed before some decisions, including referrals for restrictions on people's liberty. Information was also not recorded consistently.
“The provider had not completed Mental Capacity Assessments as required.” from the report
Staff support and training
seriousNot all staff had up-to-date mandatory training, regular supervision or appraisals. Induction records were missing for some staff, including agency staff.
“Staff were not receiving appropriate induction, training and supervision to enable them to deliver safe and effective care to people.” from the report
Management oversight
seriousAudits did not identify or resolve several problems. The home had not sustained improvements since the previous inspection.
“The service did not have a robust system in place to monitor the quality and safety of the service.” from the report
- 01What has been done to make sure medicines are given correctly, medicine stocks match the records, and the electronic medicines records update properly?
- 02What staffing levels are now in place compared with each person's dependency assessment, and how are these reviewed after new admissions?
- 03Have mental capacity assessments and best-interest decisions now been completed and recorded for every person who needs them?
- 04Have all permanent and agency staff completed induction, mandatory refresher training, supervision and appraisals?
- 05What evidence can you show that the warning notices and the problems identified by the CQC have been fully addressed and sustained?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and their ratings carried over from the previous inspection. This explanation was written from the published report of 13 January 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, December 2019
Rated Requires Improvement; inspectors found kind, respectful care but serious risks in medicines, emergency plans and oversight.
The CQC made an unannounced inspection visit on 10 December 2019. Inspectors spoke with people living at the home, relatives, staff and healthcare professionals. They also checked care records, medicines, accidents, training, complaints and management records.
People were treated with kindness, dignity and respect. Staff knew people well, supported their choices and offered activities, food, drinks and healthcare support. People and relatives gave positive feedback about the care and management.
However, medicines were not always managed safely. Some medicine instructions were missing, storage temperatures were not checked properly, and some creams and eye drops had inaccurate dates. Emergency evacuation records were out of date or missing for seven people. One person's medical condition was not covered by a care plan, and staff were unaware of it.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement, while Caring and Responsive were rated Good. The overall rating had fallen from Good at the previous inspection, published in May 2017.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors observed friendly interactions and people appeared relaxed with staff.
“People were supported and treated with dignity and respect and involved as partners in their care.” from the report
Staff skills
Staff received training, supervision and appraisals. Inspectors found they had the knowledge and skills needed to meet people's needs.
“People were well cared for by staff that had the knowledge and skills to meet people's needs.” from the report
Activities and community links
People could choose from activities such as music, quizzes, singing, baking and trips. The home also had links with local schools, community groups and religious organisations.
“Additionally, baking and trips out in a minibus once a month were available.” from the report
Clean environment
Inspectors found the home was clean and saw staff using protective clothing and hand gel to help prevent infection.
“People were protected from the risks associated with poor cross infection practice.” from the report
Medicine safety
seriousSome 'when required' medicines did not have clear instructions about when to give them or the maximum daily dose. Storage temperatures and dates on some medicines were also not managed safely.
“There were no protocols in place on the electronic medicines system showing when these medicines should be administered, the amount of be administered and the maximum permitted daily dosage.” from the report
Missing health information
seriousA care plan for one person's specific medical condition had not been completed. The manager and staff were unaware of the condition.
“The person was placed further at risk as the service manager and staff we spoke with were unaware of the condition.” from the report
Expired DoLS authorisation
seriousAll three previously authorised DoLS had expired. Two had been reapplied for, but the home had not identified that a third person's authorisation had expired.
“There was no effective system to monitor DoLS applications, authorisations, conditions or expiry dates.” from the report
Actions not completed
needs fixingThe home's audits had not reliably led to action. Ten of 11 incident records had overdue actions, and other known risks had not been dealt with.
“It was evident that 10 incident records out of the 11 recorded since 17 November 2019 had overdue actions.” from the report
- 01What changes have you made to medicine instructions, storage temperatures and the recording of opening and discard dates?
- 02Are every person's emergency evacuation arrangements now complete and up to date?
- 03How do you check that DoLS applications, authorisations, conditions and expiry dates are monitored?
- 04How do you make sure medical conditions and required eating and drinking support are recorded promptly in care plans?
- 05What system now makes sure actions from incidents, audits and inspections are completed and checked?
This was an unannounced, planned inspection covering all five CQC questions, including the premises and the care provided; the previous inspection had rated all five questions Good. This explanation was written from the published report of 31 December 2019 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
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 15 November 2010.
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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