Sydenham House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People said they felt safe at Sydenham House and with the staff who supported them. Staff received training in safeguarding adults and were aware of the procedures for reporting any safeguarding concerns. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The provider was following the MCA, and people were only being deprived of their liberty to receive care and treatment when this was in their best interests (BI) and legally authorised under the MCA. Staff understood the principles of the MCA. The provider told us they had identified further improvements were needed to ensure all MCA’s and BI decisions were in place and had taken action to implement these. People were involved in decisions about their care and supported to maintain their chosen lifestyle choices safely and supported to take positive risks. There were enough staff with the skills required to support people safely. People were safely admitted to the service and staff worked closely with health and social care professionals to ensure people received safe care. The provider had a robust recruitment process in place and ensured agency staff received an appropriate induction. The majority of the staff we spoke with told us they felt supported, were happy in their roles and received appropriate induction, training and supervision. The management team had a good oversight, to ensure the home maintained good standards of infection control and maintenance. People received their medicines safely and in a caring way. Medicines were managed appropriately and safely. Staff had received training and their competency had been assessed. Improvement had been made in all the areas we highlighted as requiring improvement at the last inspection and learning was shared within the service and across the providers organisation. Any concerns we raised during this assessment were acted upon promptly.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager gave examples of how they had identified and shared learning following events at the service. They told us the area manager and quality support manager also reviewed events, accidents, incidents, and safeguarding’s to identify any learning. Staff told us learning was shared amongst the team, this included team and organisational learning. One staff member told us, “There is definitely a learning culture, we have a meeting and discuss how things could have gone better and any learning is shared.” Another staff member told us, “If something happens here or in another home, we talk about it and how we can prevent it.”

People lived in a service where there was a culture of learning.

There were processes in place to learn. We observed improvement in all the areas we highlighted as requiring improvement at the last inspection. During the assessment, any concerns raised with the registered manager were also acted upon immediately. We reviewed the provider's electronic monitoring system where staff record accidents, incidents and safeguarding concerns. Any learning from these were shared at meetings, handovers and through messages to staff on the electronic system. A process was also in place to share learning across the organisation.

There was a process in place to ensure admission into the home was smooth and efficient. Pre-admission assessments were completed when people were moving into the home, this included when people were readmitted to the home following a hospital stay.

People spoke positively about their experience of moving to the home. One person told us, “[Deputy manager] came and visited me at my daughters’ home, all equipment was in place for when I moved in.” Another person commented, “I moved in recently, I wasn’t safe at home, it was a big decision, but I feel safe now. They visited and got all the paperwork sorted, it’s very nice here, they make you feel most welcome.”

Staff worked with trusted assessors who carried out preadmission assessments when people were moving from hospital to the home.

The registered manager told us they worked in partnership with other professionals to ensure safe systems of care when people move between services, this included trusted assessors, hospital staff and GP’s, Staff told us they had all the information they needed to support people when they moved into the home. One staff member told us, “We have all the information loaded on our phone (electronic care records can be accessed on this device), it will tell us on the handover on the phone that someone has moved in. We also get told verbally, all the care plans are detailed and on the phone.” Staff also described how they spent time with people getting to know them, their likes and dislikes and making them feel welcomed.

People spoken with said they felt safe at the home and with the staff who supported them. Comments included, “I feel safe and very happy”, “been here for almost 20 years. Been through a mix of management. New people very nice and caring. Wouldn't be here if I didn't feel safe” and “Very safe here.” Most people spoken with told us they knew who to contact should they have a concern, and their concerns were listened too. Comments included, “I have not raised anything but could speak to anyone here. No concerns”, “happy to speak up. I know faces but not necessarily the names of the senior management of the home” and “Would speak up if needed…kind management.”

The provider had a safeguarding procedure in place. Details regarding this were visible on posters throughout the home. There were systems in place to report and record safeguarding concerns within the service. This showed a process to record, report and learn to prevent from happening again. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests (BI) and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). At the last inspection, we found the provider in breach of Regulation 11 (Consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this assessment we found that improvement had been made and the provider was no longer in breach of Regulation 11. Where needed, appropriate applications were completed to authorise a person being deprived of their liberty. Improvements were needed to ensure all MCA’s and BI decisions were in place where needed. The provider had identified this as an area for improvement and had an action plan in place to address. This included senior staff being trained and coached in completing these.

People were observed to be supported by kind and caring staff.

Staff told us they received training in safeguarding adults and were aware of the procedures for reporting any safeguarding concerns. They said if they reported any concerns, they were confident that action would be taken. One member of staff said “Safeguarding is about not accepting abuse; abuse could happen all over the place. We have to report it if we see it.” Staff understood the principles of the Mental Capacity Act 2005. One member of staff said, “Consider capacity, not judging them, support them to make choices, you cannot say if they make a bad choice, it doesn't mean they don't have capacity if they don't make a wise decision.”

During the assessment site visit we observed people being supported in line with their care plans and risk assessments, for example when supporting people in line with their eating and drinking risk assessment.

People were involved in decisions about their care. People have a monthly review of their care plans and risk assessment through the 'resident of the day’ process. People were supported to maintain chosen lifestyle choices safely, and were supported to take positive risks. One person was supported to the local fair. Staff told us how the person enjoyed going on a fairground ride, and were now in the process of planning a holiday. People were supported to move freely around the home and there did not seem to be any unnecessary restrictions on people. People confirmed this and told us they were able to live their lives how they wished, should that be in their room or engaging with others in the numerous lounges which the home has to offer. Comments included, “It’s going smoothly, been here 18 months. Invited to activities if needed but not pressured to attend” and “I am able to join in with activities with games or stay in my room.”

Staff and the management team knew people well and were aware of people's risks, the support they needed to remain safe and where to find the information required.

At the last inspection, we found the provider in breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued a warning notice. This was due to a failure to ensure adequate risk and medicines management. At this assessment we found that considerable improvement had been made and the provider was no longer in breach of Regulation 12. Care plans were in place, and where people were at risk of harm assessments were carried out. Risk assessments had been completed for areas such as choking, mobility, falls, moving and handling, skin damage and Personal Emergency Evacuation Plan (PEEPS). Some of the care plans and risk assessments required additional information to ensure they provided sufficient guidance for staff. The registered manager addressed this during the assessment. Risk assessments and care plans were regularly reviewed with people, and changes made to people's care plans as needed. Records confirmed this.

The registered manager and maintenance staff were able to tell us about the systems in place to make sure the building and equipment was safe. This included regular checks and servicing by outside contractors on areas such as the fire system and moving and handling equipment. Staff told us they thought the environment was safe and any issues were reported and addressed. Staff told us regular checks were carried out on the environment, such as fire alarm checks. One staff member told us, “Fire tests are carried out and the home is well maintained. If something breaks, we report to the office and supervisor, we put it in the maintenance book and it’s done quickly they are good.”

People did not raise any concerns with the safety of the building, or the equipment used to support them. People told us the home was well maintained and the environment was safe. One person told us, “I like my room, it’s well maintained.” Another person commented, “I am happy with my room, it is well maintained, and regular fire tests are carried out.”

The service was well maintained, and equipment within the home was tested.

There was a process in place to ensure the safety of the environment. Risk assessments were in place regarding environmental risks for areas such as the laundry, kitchen, gas, equipment, cross contamination, fire and legionella. Regular checks of the environment and equipment took place, and a planned preventative maintenance policy was in place detailing the servicing of equipment frequency. Servicing of equipment was organised centrally by the organisations property team. Records viewed showed that checks on the water temperatures of 3 outlets were found to exceed the organisations recommended temperatures of 43 degrees centigrade. The registered manager told us although people had the capacity to understand the risks relating to hot water, this would immediately be rectified. We had confirmation after our site visit that these had been addressed.

The majority of staff we spoke with were happy within their roles. They told us they received appropriate induction, training, and supervision. The majority of staff we spoke with felt supported, able to raise concerns and felt listened too. Staff members told us, “The management take notes of what we said and quickly mend the problem which we raise” and “They explain to us what they do and inform us what happened during meetings.” Most staff spoken with felt staffing levels had improved, and the use of agency staff had reduced. The registered manager confirmed they had a staffing dependency tool which was regularly reviewed.

People told us there was enough staff to ensure they got the support they needed. Comments included, “Yes plenty of staff around”, “Always attentive staff, no concerns at all. Haven't had to press the call bell”, “Staff come very quick”. People told us staff knew what they were doing. Comments included, “They do [know what they are doing] , otherwise I wouldn't be here” and “Staff know what they're doing.” One person told us over their time at the home, they have felt staff were able to cater for their needs well, and that this was their home and they felt extremely comfortable. The management team were accessible within the office. People using the service knew where to go should they need anything.

At the last inspection, we found the provider in breach of Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this assessment we found that improvement had been made and the provider was no longer in breach of Regulation 18. Staff had not always received the training required. The provider had identified this as an area for improvement and had an action plan in place to address. Staff rotas were based on a dependency tool. The dependency tool and rota's viewed during the assessment evidenced there was sufficient staff covering shifts. Recruitment practices were in place to ensure only staff suitable to work with vulnerable people were employed. Agency staff were currently being used within the service. There were a range of checks in place to ensure agency staff had the right skills to undertake their role. Staff, including agency staff, were receiving appropriate induction. We were told this included any staff that were new to care being enrolled on the care certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction program. Systems were in place for staff to receive support from the management team to enable them to develop their practice and share any concerns.

On the days of the assessment, we observed there were enough staff available to respond to people’s needs. Staff were visible throughout the visits and were seen supporting people when required during mealtimes, activities and with personal care. Call bells were also observed to be ringing and responded to in a timely manner.

An Infection Prevention and Control (IPC) Policy, Procedure and Guidance was in place, and there was a process in place to ensure the home maintained good standards of infection control. Cleaning schedules were in place and records were completed when cleaning took place.

People were positive about the cleanliness of the home. One person told us, “The cleaning department are wonderful, they are very good.” Another person told us, “They [housekeeping staff] come in and clean my room every day and communal areas are cleaned.”

The registered manager told us how they ensured effective prevention to infection control measures were followed. This included the completion of audits, observations, spot checks and staff training. Staff told us the service was clean. Staff told us they had access to personal protective equipment (PPE) and they received training in infection control. The housekeeping team told us they had all of the equipment and products they needed, and they had cleaning schedules in place. One staff member told us, “We are allocated to each area of the home, and we help each other out if needed. Bedrooms have deep cleans completed for resident of the day and we sign off on the resident of the days sheet.”

The service was clean. We observed housekeeping staff carrying out cleaning tasks on both days of the inspection. There was appropriate personal protective equipment (PPE) available throughout the home.

At the last inspection, we found the provider in breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued a warning notice. This was due to a failure to ensure adequate risk and medicines management. At this assessment we found that considerable improvement had been made and the provider was no longer in breach of Regulation 12. There were policies and procedures in place to ensure people’s medicines were managed appropriately and safely. Medicines were stored securely and at appropriate temperatures. There were suitable arrangements for controlled drugs, and for medicines ordering and disposal. Records were kept of training and competency checks for staff. Any errors or incidents were reported, and regular medicines audits took place which identified any areas for improvement.

Staff told us they felt well supported regarding medicines management. Staff told us they were trained in medicines administration and had regular competency assessments. They said that there was an open culture if any errors or incidents took place, these were recorded, and actions and learning put in place to try to prevent a recurrence.

People received their medicines safely and in a caring way. They were asked if they required any of their medicines prescribed ‘when required’. Records were kept when medicines were given and showed that people received them in the way prescribed for them. People’s individual preferences for how they liked to take their medicines were considered. They could look after their own medicines after it was assessed as safe for them to do this.