Sydenham House

Updated 12 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider met the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak and to identify good practices we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors and an Expert by Experience.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Sydenham House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and for compliance with regulations.

At the time of our inspection, there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of the monitoring activity that took place on 05 May 2023 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We observed staff interacting with people and looked at the premises. We spoke to 6 people who use the service and 8 people’s relatives about their experience of the care provided. We spoke to the registered manager and deputy manager, who were also the service owners, a senior care assistant, a care assistant, and the cook.

We reviewed a range of records. This included 4 people’s care records and medicine records. We looked at 1 staff file in relation to recruitment and records relating to the management of the service, including safety checks.

Updated 12 December 2023

About the service

Sydenham House is a residential care home which accommodates up to 19 people in one adapted building. Sydenham House is registered to provide care for older adults who may be living with dementia, physical disability and/or sensory impairment. At the time of this inspection 16 people were living there.

People’s experience of using this service and what we found

We found improvements were needed to ensure people's risks were assessed and mitigated to keep them safe, such as the management of people’s weights, moving and handling and nighttime support.

We found improvements were also needed in relation to medicines administration and the management of environmental risks to people in areas such as the management of legionella and fire safety.

Improvements were also needed to strengthen the provider's quality auditing systems and processes of the service delivery.

The registered manager was aware that improvements needed to be made to the service and was in the process of addressing these.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their relatives told us they felt safe living at the service.

Staff understood their responsibility to report concerns and poor practice. Staff knew how to report any incidents and accidents.

Systems were in place to engage with staff and people who use the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 02 July 2018)

Why we inspected

We inspected this service because the previous inspection was more than 5 years ago, and we wanted to check the provider was still providing good quality and safe care. We undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Sydenham House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance.

We made a recommendation to support the provider's systems of assessing and recording people's mental capacity.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.