We carried out a review of the data available to us about Soham Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Soham Lodge, you can give feedback on this 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.
We found the following examples of good practice.
The service was only receiving essential visitors at the time of our inspection. Any person entering the building had their temperature taken, completed a health questionnaire and wore full personal protective equipment (PPE) including a face visor.
People were supported by staff in full PPE, whether that person was COVID-19 positive or negative. This is called barrier nursing. This is to protect both staff and people living in the service from spreading infection.
The senior nurse told us that they changed systems within the service to reduce the spread of infection. Medicine rounds and personal care visits had been changed so that those people with a negative diagnosis of COVID-19 were all supported first, followed by those who were positive.
The manager had put additional risk measures into place, for example cutlery and crockery used by people with a positive diagnosis were placed in a red bag and sealed. This ensured that kitchen staff took additional precautions to protect themselves and that the crockery and cutlery were washed at a higher temperature on their own.
The building was clean and free from clutter. The manager had employed additional domestic staff to support the domestic team. During our inspection we observed staff cleaning communal areas and bathrooms, and ensuring that areas regularly touched by hands were disinfected.
The manager told us that they were working collaboratively with colleagues from the Local Authority and CCG (Clinical Commissioning Group), and were well supported as a result.
Soham Lodge is a care home providing personal and nursing care to 21 people at the time of the inspection. The service can support up to 34 people.
People’s experience of using this service and what we found
Risks associated with not obtaining staff recruitment checks during the COVID-19 pandemic were not available, although the new manager completed these and took action to obtain missing information. There may not always enough staff to meet one person’s specific needs. We have made a recommendation about how to decide staffing levels.
Systems to monitor how well the home was running were carried out. Concerns were followed up to make sure action was taken to rectify any issues. Changes were made where issues had occurred elsewhere, so that the risk of a similar incident occurring again was reduced. People were asked their view of the home and action was taken to change any areas they were not happy with.
People were happy with the care home and the staff that provided their care.
People felt safe living at the home and staff knew how to report possible harm. Staff assessed and reduced risks as much as possible, and there was equipment in place to help people remain as independent as possible. The provider obtained key recruitment checks before new staff started work.
People received their medicines and staff knew how these should be given. Medicine records were completed accurately and with enough detail. Staff used protective equipment, such as gloves and aprons.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 5 February 2019).
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
The inspection was prompted in part due to concerns received about staffing levels, guidance for care staff about how to care for people and management oversight of the service. A decision was made for us to inspect and examine those risks, we undertook a focused inspection to review the key questions of safe and well-led only.
We found no evidence during this inspection that people were at risk of harm from this concern. However, we have recommended the provider considers developing a formal process to determine staffing levels.
Please see the safe and well-led sections of this full report.
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 coronavirus and other infection outbreaks effectively.
The overall rating for the service has remained the same - requires improvement. This is based on the findings at this inspection.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Soham Lodge is a care home, providing nursing and personal care and accommodation for up to 34 people some of whom live with dementia. At the time of the inspection, 23 people were living at the service. The service is in one adapted building. There is a large communal area. All bedrooms had en-suite bathrooms.
People’s experience of using this service
The provider did not carry out all the required pre-employment checks prior to staff starting work at the service. The provider could therefore not be assured that all the staff they had recruited were suitable for their roles.
The provider’s quality assurance systems were not robust enough and did not demonstrate they had systems to assess, monitor and improve the quality of the service effectively. Their audits had not identified the shortfall in staff recruitment checks.
The provider had identified their electronic records system was difficult for staff to use. To mitigate this staff had good communication systems in place to ensure they met people’s needs. Staff were being trained to use a new system for records management and showed us how easy it was for them to access information. Following our inspection, the business manager told us this had been implemented.
People told us they felt safe receiving the service. Effective systems were in place to protect people from harm. Staff had identified most risks and put plans in place to reduce the risk of avoidable harm. Staff were aware of these plans and knew how to meet people’s needs effectively. Staff knew how to raise concerns and were confident the management team would take these seriously and act on them. People’s medicines were stored and managed in a safe way. Staff followed the provider’s procedures to prevent the spread of infection and reduce the risk of cross contamination.
There were enough staff to meet people’s needs safely. People received care from staff who were trained and very well supported to meet people’s assessed needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. People were involved in making decisions about their care and support.
Staff supported people to have enough to eat and drink and maintain a healthy weight. They worked well with external professionals to support people to keep well.
Staff supported people in a kind, thoughtful, and caring way. Many people and relatives commented on staff members’ caring nature. Staff were very respectful when they spoke with, and about, people. Staff were skilled at communicating with people and supporting people when they were distressed. They supported people to maintain their independence. Support was person-centred and met each person’s specific needs.
The provider had employed a proactive activities co-ordinator who had developed a comprehensive activity programme that included one-to-one and group events, entertainers and outings. Staff encouraged people to socialise and be more active. People had opportunities to go out, such as visiting the local town, and trips further afield. Staff supported people to develop new, and maintain existing, relationships, including supporting a person to care for their pet at the service.
People were very well supported and cared for at the end of their lives. The service had achieved the Gold Standards Framework (GSF) in palliative care. This is a model of good practice that enables a 'gold standard' of care for all people who are nearing the end of their lives. We saw many compliments that relatives had sent to the service about the care their family members had received.
People and their relatives felt able to raise any concerns with the staff and management team. The provider had systems in place, including a complaints procedure, to deal with any concerns or complaints.
Staff encouraged people and relatives to regularly feedback about their care and support both formally and informally. Staff had listened and acted on people’s comments. For example, we received positive comments about how they had improved the choice of food available at tea -time.
Throughout our inspection the nominated individual, business manager, and staff all expressed a strong desire to continue to improve the service. They had developed and forged links with community groups and external care professionals. They had raised the profile of social care externally and encouraged the community into the service.
Rating at last inspection
The last rating for this service was requires improvement (published 22 December 2018) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider had made some improvements. However, the provider was still in breach of regulation 17, good governance, and we identified a new breach of regulation 19, fit and proper persons.
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement
We have identified two breaches in relation to recruitment checks and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk.
The care home accommodates up to 34 people in one adapted building. At the time of the inspection there were 32 people living in the home.
There was a registered manager in place however they were not present during the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.’
At the previous inspection in August 2017 the home was rated as Good. However, at this inspection the rating has changed to Requires Improvement.
The quality assurance system was not effective in making sure that people received the care and support they needed in a safe way. Although audits were being completed they had not found the issues we found during the inspection. Policies and procedures were in place but these were not always being followed to ensure people were being provided with the right care and support. .
Risks had not always been identified in a timely manner so that action could be taken to reduce the likelihood of accidents or incidents. Staff had not always taken the necessary action needed to reduce risks when they were identified.
Staff had not received regular supervisions or appraisals and it was not clear what training they were expected to complete. There was no training plan to ensure staff had the knowledge they required to meet people’s needs.
Information about the support people needed was not always accurate or up to date. This meant that staff were not always aware of people’s needs.
Medication was not always administered or managed safely. Management had not carried out competency checks on staff to ensure they were still competent to administer medicines safely. Not all medication administration records reflected the amount of medication in stock. This meant we could not be confident that people were always receiving their medication as prescribed,
The providers recruitment policy had not always been followed to ensure new staff were only employed once two satisfactory references had been received. Other recruitment checks such as a criminal records check had been carried out. There were sufficient numbers of staff to meet people’s needs.
People were offered a choice of food and drink. People health was placed at risk because special diets were not always followed.
Although there were policies and procedures for staff to follow regarding the Mental Capacity Act 2005 these were not always being followed in practice. This meant that people were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible.
There was a complaints procedure in place. Complaints had been dealt with appropriately. However, records of the complaint, investigation and outcome had not been easy to access and were kept in various places rather than a clear record.
Staff were aware of what action to take if they thought someone had been harmed. They were aware of the internal and external reporting procedures and were confident to use them.
Staff provided care in a kind and compassionate way. They knew people well and
were aware of their history, preferences, likes and dislikes. People's privacy and dignity were respected. Staff provided end of life care and support in a way that each individual person wanted.
You can see what action we told the provider to take at the back of the full version of this report.
This unannounced inspection took place on 1 August 2017. At the last comprehensive inspection on 27 July 2016 the service was rated as ‘requires improvement’. We undertook a focussed inspection on 16 November 2016 and found that improvements had been made. At this inspection we found overall the service remained ‘good’.
There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
Staff were clear about the procedure to follow to protect people from being harmed. Risks to people who lived at the service were identified, and plans were put into place by staff to minimise these risks and enable people to live as independent and safe a life as possible.
Staff treated people with kindness. Staff showed they genuinely cared about the people they were looking after. They respected people's privacy and dignity and encouraged people to be as independent as they could be. Visitors were welcomed and also had warm, friendly relationships with the staff.
Staff were only employed after the provider had obtained satisfactory pre-employment checks. Staff understood their roles and responsibilities and were supported by the registered manager to maintain and develop their skills and knowledge by way of supervision and observation. Staff were trained to provide safe and effective care which met people’s individual needs and they knew people’s care requirements well.
People had health, care, and support plans in place which took account of their needs. These recorded people’s individual choices, their likes and dislikes and any assistance they required. Medicines were well managed and people received their medicines as prescribed.
Staff supported people to make everyday decisions in the least restrictive way possible. The policies and systems in the service supported this practice.
People and their visitors were able to raise any suggestions or concerns they might have with the registered manager. They said that they felt listened to as communication with the registered manager and staff team was good.
Arrangements were in place to ensure the quality of the service provided for people was regularly monitored. We found that people who lived at the service and their visitors were encouraged to share their views and give feedback about the quality of the care and support provided.
Further information is in the detailed findings below.
After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.
We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.
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’
Soham Lodge provides accommodation, personal care and nursing for up to 34 people including those living with dementia or requiring mental health support. Accommodation is located over one floor, with communal areas for people and their visitors to use. There were 26 people living in the home when we inspected.
At the time of this inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
At our focused inspection on 4 November 2016, we found that the provider had followed their plan which they had told us would be completed by 30 June 2016, and legal requirements had been met.
Records showed that notifications had been submitted to the CQC in a timely manner.
Arrangements were in place to ensure that people’s medications were stored, administered and disposed of safely. Records regarding the administration of people’s prescribed medication were kept.
This unannounced inspection took place on 23 and 24 May 2016.
At the time of the inspection the manager was in the process of applying to the Care Quality Commission [CQC] to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
Not all staff were following the correct procedures when administering medication. Medication was stored securely and medication administration records were accurate
The provider had not notified the CQC of all events as required.
The CQC is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was acting in accordance with the requirements of the MCA including the DoLS. The provider could demonstrate how they supported people to make decisions about their care and the principles of the MCA were being followed.
There were enough staff on shift to ensure that people had their needs met in a timely manner. Not all staff were aware of what actions to take if they thought that someone had been harmed in any way. Risks to people had been assessed and the necessary action had been taken to reduce the risks where possible.
The recruitment process had been followed to ensure that staff were only employed after satisfactory checks had been carried out. Staff received the training they required to meet people’s needs and were supported in their roles.
Staff were kind and caring when working with people. They knew people well and were aware of their history, preferences, likes and dislikes. People’s privacy and dignity were usually respected.
Staff monitored people’s health and welfare needs and acted on issues identified. People had been referred to healthcare professionals when needed. People were provided with a choice of food and drink that they enjoyed. Staff supported people to maintain their interests and their links with the local community to promote social inclusion.
Care plans and risk assessments gave staff the information they required to meet people’s care and support needs.
There was a complaints procedure in place and people and their relatives felt confident to raise any concerns either with the staff or manager.
People’s views about the quality of the service were being obtained.
We found one breach of the Health and Social Care Act 2008 Registration Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.
We carried out an unannounced comprehensive inspection of this service on 19 March 2015. One breach of legal requirements was found. This was because the storage, administration and recording of medication did not always protect people against the risks associated with unsafe use and management of medicines.
After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook this focused inspection on 1 December 2015 to check that they had followed their plan and to confirm that they now met legal requirements.
This report only covers our findings in relation to those requirements. 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.
Soham Lodge provides accommodation for up to 26 people who require personal care or nursing care. The home provides support for older people, some of whom are living with dementia. There were 24 people living in the home at the time of our inspection.
There was a new manager in post at the time of the inspection but they were not yet registered with the commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
At our focussed inspection on 1 December 2015 we found that the provider had followed most of their plan which they told us would be completed by 10 June 2015 and legal requirements had been met.
Since the last inspection changes had been made so that people had sufficient medicines available in the home. They were supported to take their medicines at the prescribed time and in line with the prescriber’s instructions.
Training in medicine administration could not be evidenced and was to be completed again on 19 January 2016.
Medicines were stored safely and at the correct temperature and audits had been completed.
The processes in place to audit systems were not robust enough. This meant that the provider was not able to assess, monitor and improve the quality and safety of the service.
We carried out an unannounced comprehensive inspection of this service on 19 March 2015. One breach of legal requirements was found. This was because the storage, administration and recording of medication did not always protect people against the risks associated with unsafe use and management of medicines.
After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook this focused inspection on 1 December 2015 to check that they had followed their plan and to confirm that they now met legal requirements.
This report only covers our findings in relation to those requirements. 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.
Soham Lodge provides accommodation for up to 26 people who require personal care or nursing care. The home provides support for older people, some of whom are living with dementia. There were 24 people living in the home at the time of our inspection.
There was a new manager in post at the time of the inspection but they were not yet registered with the commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
At our focussed inspection on 1 December 2015 we found that the provider had followed most of their plan which they told us would be completed by 10 June 2015 and legal requirements had been met.
Since the last inspection changes had been made so that people had sufficient medicines available in the home. They were supported to take their medicines at the prescribed time and in line with the prescriber’s instructions.
Training in medicine administration could not be evidenced and was to be completed again on 19 January 2016.
Medicines were stored safely and at the correct temperature and audits had been completed.
The processes in place to audit systems were not robust enough. This meant that the provider was not able to assess, monitor and improve the quality and safety of the service.
Soham Lodge is registered to provide accommodation and nursing care for up to 26 people. There were 22 people living at the home when we visited. The home is on one floor with two dining and lounge areas and single bedrooms. There is an enclosed garden area.
This unannounced inspection took place on 19 and 23 March 2015. The previous inspection was undertaken on 21 February 2014 when we found that the regulations which we assessed were being met.
At the time of the inspection there was no registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
Not everyone received their medication as prescribed and safe practices had not always been followed in the administration, recording and storing of medicines.
People felt safe and staff knew what actions to take if they thought anyone had been harmed in anyway.
People confirmed that there were enough staff available to meet their needs but that they would like it if staff had more time to sit and talk to them. Other than when staff were attending a short meeting call bell’s were responded to promptly and people were not rushed when being assisted by staff.
Staff monitored people’s health and welfare needs and acted on issues identified. People had been referred to healthcare professionals when needed. Not all nurses employed to work in the home had the competencies they required to meet people’s nursing needs. These needs had been met by the district nurses.
The requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were being followed to ensure that when needed decisions were made in people’s best interests and they were not having their liberty restricted unless the correct procedures were followed.
People enjoyed the food and always had enough to eat and drink. When needed, people were given the support to eat and drink.
Staff were kind and compassionate when working with people. They knew people well and were aware of their history, preferences and likes. People’s privacy and dignity were upheld.
People had been involved in the assessment and planning of their care. Care records were detailed and gave staff the information they required so that they were aware of how to meet people’s needs.
There was a complaints procedure in place and people felt confident to raise any concerns either with the care staff or the manager.
A management company had been appointed to oversee the running and of the home and had appointed a new manager. The management company had an action plan in place to make ensure improvements were made where necessary.
We found a breach of the Health and Social Care Act 2008(Regulated Activities) Regulations 2010 which correspond to breaches of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.
We found that staff were caring and attentive to people's needs. We saw that people had enough to eat and had access to snacks throughout the day. The service had a dedicated activities co-ordinator that worked with people and their relatives to deliver tailored activities on an individual basis and in groups.
We saw that the service had effective working relationships with other providers and accessed other professionals to support people when this was required. The registered manager told us that the hospitals worked well with them to support people who were being admitted or being discharged.
We saw that the service had effective quality assurance processes in place to monitor the dementia care people received.
We found that the warning notice had been complied with as the provider had ensured that the records in relation to the people living in the home had been updated and were an accurate record of their needs and the care and treatment that they were receiving.
We also found that the provider had taken proper steps to ensure that each person had an assessment of their needs and a care plan in place so that the staff had the information they required to meet people's needs in a safe manner. We talked with people living in the home and they were all complimentary about the care they had received, one person told us "I like living here, the home couldn't be improved". One relative of a person living in the home told us "Since the new manager has been here it is much better. My (relative) is always treated with absolute dignity". The records showed that when people's needs had changed the assessments and care plans had been updated to ensure that people still received the care that they required.
The effective recruitment policy and procedure in place was followed to ensure that the right people had been employed.
We found that improvements had been made to the assessments and care plans although these were not all up to date and accurate. We found that not all of the care plans were being followed by all staff and this could place people at risk of receiving unsafe or inappropriate care.
One person told us about an event that had made them feel unsafe and how the staff had taken appropriate actions so that it would not happen again. We found that care plans did not all accurately reflect people's needs and that not all treatment provided by the nurses had been recorded. There were discrepancies between the medication administration records and the stock levels of medication. Staff were aware of what process they should follow if they thought someone had been abused. Recruitment procedures were not always followed to ensure that the right people were employed. The provider told us what they thought the minimum staffing levels should be but these had not always been maintained. Staff had received mandatory training and supervision.