• Care Home
  • Care home

Archived: Sydmar Lodge

Overall: Requires improvement read more about inspection ratings

201 Hale Lane, Edgware, Middlesex, HA8 9QH (020) 8931 8001

Provided and run by:
Embrace All Limited

Important: The provider of this service changed. See new profile

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Background to this inspection

Updated 15 June 2016

We carried out this inspection under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This was a planned inspection to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We undertook this unannounced focussed inspection at Sydmar Lodge on 17 May 2016. The inspection was completed to check whether the provider had addressed the breach of regulations arising from the inspection on 24 August 2015, that people were not protected against the risks associated with the unsafe management of medicines.

We inspected the service against one of the five questions we ask about services: Is the service safe? This was because the service was not meeting legal requirements in relation to that question on our previous visit.

A Pharmacist Inspector carried out this inspection. We reviewed the information the provider had sent to us about the actions they had taken following our previous visit before carrying out the inspection. During this inspection we spoke with the manager of the home, the deputy manager and two senior care staff with responsibility for medicines. We also spoke to three people using the service, and checked the medicines records for thirty people.

Overall inspection

Requires improvement

Updated 15 June 2016

We carried out an unannounced focussed inspection on the 17 May 2016. This meant the staff and provider did not know we would be visiting.

Sydmar Lodge provides accommodation for up to 57 people who require support with their personal care. The service provides support for older people and people living with dementia. At this inspection, the manager informed us there were 40 people using the service during the inspection. The premise is a purpose-built care home with passenger lift access to the first and second floor.

The provider recently employed a new manager who was in the process of applying to become the registered manager for the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We previously visited this service for an unannounced focussed inspection on 24 August 2015. During that visit, we found that people were not protected against the risk associated with the unsafe management of medicines, which was a breach of regulations.

At this focussed inspection, we checked to see that improvements had been implemented by the service in order to address the breach of regulations. This report only covers our findings in relation to that. Reports from our last comprehensive inspections are available on our website by selecting the “all reports” link for Sydmar Lodge at www.cqc.org.uk.

At this inspection on 17 May 2016 we looked at arrangements for the management of medicines and found that improvements had been made. We reviewed the provider’s action plan and saw evidence of the actions they had taken.

We looked at the management of medicines. There were concerns at the last inspection that people may not have been receiving their medicines as prescribed. We saw improvements had been made to the ordering process for repeat medicines to ensure people got their medicines on time and that regular stock checks were being carried out. We found no incidences on this inspection where people had not received their medicines as prescribed. This was an improvement in comparison with our previous visit.

We have, however, made a recommendation about the management of medicines. This is because some staff who administer medicines had not received appropriate training. There was also no documentation of regular pain assessment or the use of any pain assessment tools. This meant that people’s pain may not be appropriately managed, especially for those with dementia whose medicines were prescribed as ‘when required’.