CQC report explained · a residential care home
What the CQC found at Cambridge House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had enough staff and were supported by staff who understood their needs. Medicines, infection control, safeguarding and fire safety were managed well, although an external area still needed repair.
- Effective?
- Good
- This question was not inspected in this report, so no rating is given here.
- Caring?
- Good
- This question was not inspected in this report, so no rating is given here.
- Responsive?
- Good
- Care plans reflected people's needs and communication methods. People had more opportunities to use the local community and take part in activities, although some minor recording issues remained.
- Well-led?
- Good
- The manager and staff knew people well and had made improvements since the previous inspection. Most relatives and staff gave positive feedback, but some relatives reported poor communication.
What inspectors found, September 2023
Cambridge House is rated Good; inspectors found safe, person-centred care and clear improvements, but communication and some records needed attention.
Inspectors visited on 28 June and 31 July 2023. They met all five people living there, observed staff, spoke with staff, the manager, relatives and health professionals, and checked care records, medicines, risks and recruitment files.
The home was rated Good for Safe, Responsive and Well-led. People had enough trained staff, medicines were managed safely, care plans were personalised, and people had more opportunities to go out and take part in activities. New fire doors had also been fitted.
The previous rating was Requires Improvement. Inspectors found that earlier problems had been addressed and the home was no longer in breach of regulations. They noted some minor care-record issues and concerns from a few relatives about communication.
Improved safety
The home had replaced all its fire doors with safety-compliant doors. This addressed a problem found at the previous inspection.
“At this inspection we found the works had all been completed and new safety compliant fire doors had been fitted.” from the report
Safe medicines support
Staff gave medicines as prescribed and followed people's medicines records and care plans. The home also worked to avoid unnecessary over-medication.
“The service took steps to ensure people's anxiety or distress was not controlled by excessive or inappropriate use of medicines.” from the report
Personalised communication
Staff used communication methods suited to each person, including sign language and pictures, to support everyday choices.
“We saw that staff used these methods with people when making daily decisions such as choosing a drink or an activity.” from the report
More community activities
People had greater opportunities to go out and take part in leisure and social activities in the local community.
“People were supported to access the local community and participate in a range of activities such as going to the cinema, hydrotherapy and to a local splash pad.” from the report
Stable staff team
Many staff had worked at the home for five years or more. This meant they knew people's communication needs and health requirements well.
“Many of the team had worked with people at the service for 5 years, or more, and understood people's non-verbal communication needs and complex healthcare requirements.” from the report
Minor record-keeping issues
minorInspectors found some minor issues in care and support plans. The manager was aware and was working to address difficulties with the care-planning system.
“We found some minor recording issues within people's care and support plan.” from the report
External area needed repair
needs fixingAn outside area needed fixing after work by a neighbouring property. The manager was arranging for this to be completed.
“We noted an external area of the service needed fixing following some work by a neighbouring property.” from the report
Communication with relatives
minorMost relatives said communication was good, but a few reported that calls and emails were not always answered or returned.
“Communication could be better…[staff] don't always answer the phone or respond to emails.” from the report
- 01How are you checking that the minor care-plan recording issues have been fully corrected?
- 02What work remains to fix the external area, and when will it be completed?
- 03Who should relatives contact if calls or emails are not answered promptly?
- 04How will you make sure people continue to have regular community activities and outings?
- 05Can we see the previous comprehensive inspection report and discuss the improvements made since then?
This inspection covered Safe, Responsive and Well-led; Effective and Caring were not inspected in this report, and the report says ratings for questions not inspected were carried over from the last inspection. This explanation was written from the published report of 5 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found kind and effective care, but safety, activities and management systems still needed significant improvement.
Inspectors visited on 28 April and 19 May 2022. They met all five residents, spoke with relatives and staff, observed care and checked care, medicines, training and management records. The inspection also included a review of infection control and a separate look at oral health and access to dentists.
The home had enough staff to meet people's needs while they were at home. Staff knew residents well, treated them kindly and supported medicines, health appointments, communication and daily living skills. The Effective and Caring questions were rated Good.
There were important gaps. Fire doors needed work to meet safety regulations, and this had not been completed. Residents had limited planned opportunities outside the home, and records did not always show choices, meaningful activities or personalised risk assessments in enough detail. The Safe, Responsive and Well-led questions were rated Requires Improvement.
The overall rating remained Requires Improvement, as it had been at the previous three inspections. Inspectors recognised some progress, including better staffing and mental capacity records, but said improvements had not yet been sustained or fully embedded.
Kind and respectful care
Inspectors observed kind and compassionate care. Relatives also said staff treated their family members well.
“Staff were observed treating people with kindness, compassion and care.” from the report
Medicines were managed safely
Medicines were stored and given safely. Records checked showed medicines had been given as prescribed, and the home understood the need to avoid over-medication.
“We found these were completed in full and showed people received their medicines as the prescriber intended.” from the report
Staff understood residents
Staff knew residents' needs, preferences and non-verbal ways of communicating. They used pictures, sounds, facial expressions and body language to support choices.
“Staff understood and encouraged the individualised way people communicated their wishes and choices.” from the report
Training and support
Staff received induction and individualised training, including training from health professionals for specific support needs. Staff said they felt supported by the manager.
“Staff were trained to support the people they looked after safely and effectively.” from the report
Improved legal decision-making
Since the previous inspection, the home had made DoLS applications and recorded mental capacity and best-interest decisions where needed.
“At this inspection we found staff had made DoLS applications, recorded mental capacity assessments and any best interest decisions.” from the report
Fire doors were not yet compliant
seriousAn external fire risk assessment found that fire doors needed repair or replacement. Quotes had been obtained, but there was no completion date when the report was written.
“This is a risk to people's safety. This is a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Improvements were not embedded
seriousThe provider's audits and oversight had not driven enough timely improvement. The home had been rated Requires Improvement at the previous three inspections.
“Improvements made had not been sustained or embedded.” from the report
Too few activities outside the home
needs fixingResidents had some activities and interests at home, but opportunities for leisure and social activities away from the home were limited and needed advance planning.
“There were limited opportunities for people to pursue leisure and social interests outside of the home.” from the report
Records were not always detailed enough
needs fixingSome records did not fully show residents' choices, meaningful use of time or individual risks. The kitchen risk assessment did not explain each person's risks and support needs in enough detail.
“The kitchen safety risk assessment was not individualised to each person and their individual risks when entering the kitchen.” from the report
Some people lacked an NHS dentist
minorSome residents had attended dental appointments, but others were not registered with a dentist after COVID-19 disruption and a local dentist closing.
“However due to a combination of COVID-19 and a community dentist closing, some people were now not registered with a dentist.” from the report
- 01Have the fire doors now been repaired or replaced, and what temporary measures were used until the work was completed?
- 02What regular activities outside the home can each resident now access, and how are staffing arrangements planned to make this possible?
- 03How have you made each resident's kitchen access risk assessment individual and person-centred?
- 04How will you show, in care records, the choices residents make and how they spend their time meaningfully?
- 05Which residents are still not registered with a dentist, and what steps are being taken to secure access to dental care?
This inspection assessed all five CQC questions, with additional checks on infection prevention and control and a thematic probe about oral health and access to dentists. This explanation was written from the published report of 29 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Cambridge House
6 rated inspections over 8 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2022Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 1 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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23 live-in carers within about an hour of Suffolk
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