Soham Lodge

Updated 16 March 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 was meeting 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 practice we can share with other services.

Inspection team

This inspection was carried out by an inspector 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

Soham Lodge 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. Soham Lodge is a care home with nursing care. 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 compliance with regulations.

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

Notice of inspection

This inspection was unannounced.

We visited the service on 13 February 2023 and on 02 March 2023.

What we did before the inspection

We used information gathered as part of monitoring activity that took place on 16 February 2022 to help plan the inspection and inform our judgements.

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, the Cambridgeshire and Peterborough Integrated Care System (ICS) and professionals such as the fire service who work with the service. 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 all this information to plan our inspection.

During the inspection

We spoke with 6 people who used the service and 1 relative. We received feedback from the local authority, the fire service and the Cambridgeshire and Peterborough Integrated Care System (ICS) about the service. We spoke with 7 members of staff including the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We spoke with 2 nurses, and 2 senior care staff and a physio assistant. We also spoke with a visiting health professional.

We reviewed a range of records, this included 5 people's care records. We looked at medicines’ records and 4 staff files in relation to recruitment. A variety of records relating to the management of the service were also reviewed, including incident and accident records, utilities safety checks, staff rotas and staff dependency tools, quality assurance processes and policies.

After the inspection

We received confirmation and risk assessment about a staffs right to work in the UK.

Updated 16 March 2023

About the service

Soham Lodge is a care home providing personal and nursing care to 26 people at the time of the inspection. The service can support up to 34 people. The service provides support to older and younger adults with dementia, nursing needs and mental health needs in one adapted building.

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

Staff knew people’s individual needs, wishes and preferences well. Risks to people were assessed and monitored by staff. Staff responded to people’s changing care and support needs. People’s care plans and records were reviewed and updated when changes occurred.

Staff used their training and knowledge to safeguard people wherever possible and to try to keep people safe. If staff had any concerns about people, they knew where to report this both inside and outside of the service. People received their medicines as prescribed and staff followed infection prevention guidance and good practice. Staff listened to and respected people’s choices and wishes.

Recruitment checks were carried out to help ensure staff were suitable to work and had a right to work at the service. There were enough skilled staff to support people’s nursing, care and support needs. The registered manager monitored staffing levels by using a dependency tool and told us they would change the number of staff working to meet people’s needs.

Governance systems were in place to monitor the service and helped in identifying and driving improvements needed. The registered manager and staff team acted when learning from any incidents that may have occurred. Surveys to feedback on the quality of the service provided were completed by people. Staff attended meetings to hear updates on the service and people could also attend meetings to discuss the service and raise any suggestions or concerns they may have had.

The registered manager and staff team worked well with other organisations such as health and social care professionals to provide people with joined up care. The registered manager was aware of all the incidents they were legally obliged to notify the CQC of.

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.

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 requires improvement (published 19 November 2020).

At our last inspection we recommended that the provider considered current guidance to formalise a process to identify appropriate staffing levels. At this inspection we found the provider had acted on the recommendation and were now using a dependency tool to calculate safe staffing numbers.

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result, 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 requires improvement to good based on the findings of this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Soham Lodge on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.