CQC report explained · a residential care home
What the CQC found at Sydmar Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to protect people from abuse, manage risks, prevent infection and use medicines safely. They recommended strengthening procedures based on national health and safety guidance, and found a few medicines recording errors.
- Effective?
- Good
- People received prompt healthcare support and good help with eating and drinking. Staff had appropriate training, and the home worked well with healthcare professionals.
- Caring?
- Good
- Staff treated people with kindness, patience and respect. Inspectors saw good relationships, attention to privacy and support for family and social connections.
- Responsive?
- Outstanding
- The home provided a broad and varied programme of activities, including support for personal interests and cultural traditions. Care was personalised around people's needs, preferences and routines.
- Well-led?
- Good
- Inspectors found a positive culture and clear leadership. The management team listened to concerns, worked with other agencies and gave people, families and staff opportunities to help develop the service.
What inspectors found, May 2018
Rated Good; inspectors found safe, kind and effective care, with Outstanding support for activities and personal preferences.
This was an unannounced comprehensive inspection on 10 and 17 April 2018. Inspectors spoke with people living at the home, relatives, staff and healthcare professionals. They also looked at care plans, medicines records, staff files, the building and management records.
The home was rated Good overall. Safe, Effective, Caring and Well-led were rated Good. Responsive was rated Outstanding. Inspectors found respectful care, good staffing arrangements, clean premises, safe medicines systems and strong support with healthcare, eating and drinking.
The home had improved since the February 2017 inspection, when it was rated Requires Improvement and had two legal breaches. Care records and communication were better, and earlier concerns about Legionella and lift maintenance had been addressed. Inspectors made a recommendation to strengthen health and safety procedures, and found a few medicines recording issues that were promptly corrected.
Personalised activities
The home offered a wide range of activities and adapted them to people's interests, including people who tended to stay in their rooms. Inspectors saw strong engagement in music, outings and other events.
“We found the twice-daily activity programme to be outstanding in its breadth and depth.” from the report
Kind and respectful staff
People, relatives and professionals praised staff for being kind, patient and familiar with people's individual needs. Inspectors saw respectful interactions and support for privacy and dignity.
“Staff approached people respectfully and with patience at all times.” from the report
Healthcare support
The home worked closely with community healthcare professionals and responded promptly when people's health changed. Inspectors found this helped people receive effective care and support.
“The service had strong links with community healthcare professionals, which particularly helped people to receive prompt and effective healthcare support.” from the report
Food and drink support
The home assessed nutritional needs carefully and used creative approaches to help people eat safely and enjoy meals. Staff monitored weight, food and fluid intake and sought dietitian advice when needed.
“The service was very capable at supporting people to eat and drink well.” from the report
Medicines records
needs fixingSome instructions for medicines given when needed were not specific to the person. Two records had the wrong person's name, and inspectors found a minor recording error that the checking system had missed. The records were corrected promptly.
“For example, two records had the wrong person's name recorded on them.” from the report
Health and safety procedures
needs fixingEarlier concerns about Legionella and lift maintenance had been addressed. However, inspectors recommended reviewing national health and safety guidance and embedding the related procedures.
“We recommend the provider review national guidance on health and safety in care homes and embed procedures relating to this.” from the report
- 01How do you make sure instructions for medicines given when needed are correct and specific to each person?
- 02How do you check that medicines administration records are accurate and that errors are identified promptly?
- 03What procedures are now in place following the recommendation to review national health and safety guidance?
- 04How would you involve someone who prefers to stay in their room in activities and social contact?
- 05How do you support each person's cultural, religious, food and daily routine preferences?
This was an unannounced comprehensive inspection covering the overall quality of the service and all five key questions. This explanation was written from the published report of 25 May 2018 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, April 2017
Rated Requires Improvement; inspectors found kind, responsive care, but safety and management systems were not reliable enough.
This was an unannounced inspection on 21 and 28 February 2017. The inspection included visits, conversations with people living in the home, relatives, staff and healthcare professionals, and checks of care plans, medicines records, staff files and management records.
The home was rated Good for Effective, Caring and Responsive. Inspectors found kind staff, good healthcare support, safe medicines management, improved care plans and a wide range of activities. People and relatives were generally satisfied, although some felt there were not enough staff and responses to call bells could be slow.
The home was rated Requires Improvement for Safe and Well-led, making the overall rating Requires Improvement. Inspectors found that risks linked to Legionella had not been dealt with and that some care, handover and incident records were incomplete or inaccurate.
The report describes clear improvement under the new registered manager. Some changes were made during or after the inspection, but the report still found two legal breaches and said the home needed to show that safety and management systems were working consistently.
Kind and respectful staff
Inspectors saw staff treating people warmly and with care. Recruitment and staff development included checks on dignity, communication and caring attitudes.
“There was praise of how committed and kind staff were.” from the report
Safe medicines
Medicines were available, stored properly and recorded accurately. Staff administering medicines had training and competency checks.
“People's medicines were safely managed, and people were protected from abuse.” from the report
Activities and community links
The home offered regular activities, entertainers, choir sessions and weekly trips out. People were also supported to keep links with local groups and visitors.
“The service provided an extensive range of activities and entertainers that many people enjoyed.” from the report
More personalised care plans
Care plans had been substantially reviewed and generally reflected people's preferences, life histories and needs more clearly.
“People's care plans had been recently improved on and so better reflected their individual needs and preferences and the care that they received.” from the report
Hot water and Legionella risk
seriousProfessional advice about Legionella and boiler temperatures had not been acted on promptly. At the time of drafting the report, the home had not provided evidence that the hot water systems were safe to use.
“the provider had not supplied evidence to demonstrate that in respect of the control of Legionella risk, hot water systems in the premises was safe to use.” from the report
Delays when people asked for help
needs fixingSome people and relatives felt staffing was not always enough, especially at night. Inspectors saw one call bell active for over 13 minutes and another person waiting 35 minutes for indigestion medicine.
“They asked three different staff members across a period of 35 minutes before the person was provided with the medicine.” from the report
Incomplete and inaccurate records
needs fixingSome care, handover and incident records were missing or inaccurate. This made it harder for the home to show that actions and risks were being followed up properly.
“there were some weaknesses in terms of service-wide communication and ensuring consistently accurate care records.” from the report
- 01What action has been completed to control the Legionella risk, and can you show us the latest boiler temperature records and safety checks?
- 02How many care staff are on duty during the day, evening and night, and how do you monitor call-bell response times?
- 03How do senior staff now check that care records, handovers and incident records are complete and accurate?
- 04What evidence can you show that the two legal breaches identified in this report have been fully addressed?
- 05How are residents and relatives involved in checking whether the improvements under the new registered manager have lasted?
This was a comprehensive, unannounced inspection covering all five quality questions and providing an overall rating for the home. This explanation was written from the published report of 27 April 2017 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 Sydmar Lodge
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- May 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- April 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016
Registered with the Care Quality Commission on 1 December 2016.
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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