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Sydenham House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 31 December 2019

About the service:

Sydenham House is registered to provide accommodation with personal care for up to 49 people. When we visited, 43 people lived there, however four people were in hospital.

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

People were supported by staff that were caring and treated them with dignity and respect. Feedback we received from people and their relatives about care provision and staff was positive. We made observations that people were relaxed in the company of staff.

Governance systems included internal and provider level audits and regular checks of the environment and service to ensure people received good care. We found these systems were not always fully effective in driving improvement. Whilst it was not evident this had any significant impact on people, it did not evidence a fully effective governance system was in operation and placed people at risk.

Not all risks in relation to the management of medicines were managed safely and this placed people at risk. We reviewed the plans in place to support people safely from the building during an evacuation. Some of these were either inaccurate or not completed, placing people at risk. We found for one person who had a specific medical condition a care plan on the management of the condition had not been completed. The service management and some staff were not aware of this person’s condition.

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. However, the policies and systems in the service had not ensured that all of the people who were deprived of their liberty were done so with the appropriate legal authority.

Staff had received safeguarding training and the service had appropriate safeguarding systems and processes. Staff we spoke with were knowledgeable about when and how to report safeguarding concerns. There were effective systems that ensured the service and environment were safe.

People were supported by staff who received regular training and had the skills and knowledge to meet their needs. Staff told us they were well supported by the service management and commented positively on the service leadership. The service worked together with a range of healthcare professionals to support people where needed.

Since 2016 onwards all organisations that provide publicly funded adult social care are legally required to follow the Accessible Information Standard (AIS). The standard was introduced to make sure people are given information in a way they can understand. There was evidence that where needed, the service supported people to communicate and understand through the use of pictorial aids.

People's concerns and complaints were listened to and responded to. People and their relatives commented positively about the service management and the quality of care provided. People spoke positively about the activity provision within the service, and there were a number of links between the local community and Sydenham House.

For more details, please see the full report which is on the CQC website at

Rating at last inspection:

The last rating for this service was Good (published May 2017)

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety and will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 31 December 2019

The service was not always safe.

Details are in our Safe findings below.


Requires improvement

Updated 31 December 2019

The service was not always effective.

Details are in our Effective findings below.



Updated 31 December 2019

The service was caring.

Details are in our Caring findings below.



Updated 31 December 2019

The service was responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 31 December 2019

The service was not always well-led.

Details are in our Well-Led findings below.