- Care home
Sydenham House
Report from 16 February 2024 assessment
Contents
On this page
- Overview
- Shared direction and culture
- Capable, compassionate and inclusive leaders
- Freedom to speak up
- Workforce equality, diversity and inclusion
- Governance, management and sustainability
- Partnerships and communities
- Learning, improvement and innovation
Well-led
The provider had a strategic plan in place which detailed their mission and values, as well as plans for 2024 onwards. Staff knew the aims of the organisation and felt they were able to speak up and be listened to. The culture of the home was open, honest and transparent with people and staff treated fairly and their diversities respected. During the assessment process the manager registered with CQC as the Registered manager at Sydenham House. They were passionate about delivering a high standard of compassionate care at the service. Staff worked in partnership with other health and social care professionals to ensure people received the care and treatment they need. The provider had a schedule of quality assurance systems in place to support them to be able to review and assess the service delivery. They gave staff, people and relatives the opportunities to provide feedback, which was acted upon. There is oversight by the provider with regular provider visits and provider level audits.
This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.
To support the vision and culture of the service, the provider had a strategic plan in place which details the organisations mission and values, as well as their plans for 2024 onwards.
Staff were happy within their roles and spoke positively about the people they supported, their work and the management team. One staff member told us, “I love coming into work, the team are very good, I am happy here, communication between the staff team is really good.” Staff told us their aim was to, “Make it as homely and as friendly as possible, a home from home” and “Provide as much happiness and make them feel comfortable and welcome, make them smile and try and brighten their day.” The registered manager told us the culture of the home was open, honest and transparent. The company values were displayed within the home. The registered manager told us these were used during recruitment to ensure new staff recruited share the same ethos. The registered manager was aware of their role and legal responsibility to be honest with people when things go wrong and to report and learn from any incidents. During the assessment the registered manager gave an example of an incident which resulted in a duty of candour letter being sent to the persons family.
Capable, compassionate and inclusive leaders
At the beginning of our assessment there was a manager who was new in post and was in the process of registering with the Care Quality Commission (CQC). During the assessment this process was completed, and the manager was registered with the CQC.
The registered manager was passionate about delivering high standard and compassionate care which was person centered to meet people’s needs. Staff provided positive feedback about the management of the service. Staff members told us, “The management team are brilliant, approachable, nice and helpful”, “there are not words in the dictionary to describe [the management], they are fantastic, they work together well, I like them as a team as well as separately”, During the assessment, any concerns we raised to the registered manager were acted upon immediately and rectified during the assessment.
Freedom to speak up
There were numerous processes in place to ensure staff felt they were able to speak up. This included ‘Speak up’ champions who feed into the board of the organisation and ‘Ask Us’ where staff can email the provider anonymously with any concerns.
The registered manager told us the culture of the home was open and honest, and that they had an open door policy when in the office. Staff felt confident to speak up and that they would be listened to. Staff told us there was an open culture where they were able to raise any concerns. They were aware of the whistleblowing procedure and knew how to report any concerns externally if required. One staff member told us, “We are definitely encouraged to speak up, even on each shift [registered managers] door is always open, its good knowing you will have that support and they will listen.”
Workforce equality, diversity and inclusion
The service had an Equality, diversity and Inclusion Policy in place and staff received ‘Promoting Equality, Diversity and Inclusion’ training.
The registered manager gave examples of how they ensured diversity was valued and staff’s individual choices were respected. Staff told us they were treated fairly and respected by the management team.
Governance, management and sustainability
At the last inspection, we found the provider in breach of Regulation 17 (Good Governance) 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 oversight of the service and monitoring of care delivery, systems, and processes. At this assessment we found that considerable improvement had been made and the provider was no longer in breach of Regulation 17. There was a schedule of quality assurance systems in place to support the management team review and assess the service delivery. Audits and checks were carried out on people’s care and where issues had been found, action plans had been put into place to address the areas of concern. The provider also visited the service regularly to carry out provider level audits.
The service had a management structure in place with defined roles and responsibilities. The registered manager told us about the systems in place to support them to review and assess the service delivery. This included a daily head of department meeting to discuss and share any current or ongoing issues and actions that needed to be taken. Staff were aware of their roles and responsibilities. One staff member described how any issues identified within the department they worked was taken to the daily head of department meeting and discussed.
Partnerships and communities
People were seen by appropriate professionals to meet their needs. One person told us they get regular blood tests and are informed of the results including any concerns that may arise. Another person told us the doctor is easy to get hold of and visit in person if needed.
There were processes in place to ensure the service worked in partnership with other professionals to make sure people received the care and treatment they needed. This included GP’s, district nurses, speech and language therapists, physiotherapists, occupational therapists, social workers and advocates.
During our assessment we sought feedback from 5 professionals. Comments included, “I feel that we work ok together, our service is needed to support some of the individuals to stay within a residential environment. They listen to advice we give and usually act upon requests we have made”, “I have not worked with them long, but it has been a very positive experience. Even when I have turned up unannounced, [Registered manager] and [Deputy manager] have been happy to accommodate me and discussions have been honest and transparent. I feel it is a good working relationship”, “[Registered manager] and [Deputy manager] promptly act on advice and give honest feedback. Good communication and happy to discuss alternatives as they (and their staff) know their residents very well” and “Sydenham house is a very lovely residential home to work with. They are always focused on the best interests of their residents, and they are passionate about the care. We as a team enjoy working with them and have no ongoing concerns.”
Staff told us there were good links with other professionals to ensure people received the care support they required.
Learning, improvement and innovation
There were systems in place to support learning and improvement in the home. These included observations, audits and opportunities for staff, people and relatives to provide feedback.
The registered manager was passionate and determined to continuously improve the service. We observed improvement in all areas we highlighted as requiring improvement since the last inspection. Staff told us they were informed of any areas where improvements were needed. The registered manager told us about innovative equipment that had been purchased to support people. This included an interactive activity touch table that supports interaction, communication and sensory experiences.