CQC report explained · a nursing home
What the CQC found at Comberton Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always stored correctly or recorded on medicine charts. Inspectors also found insufficient staffing and gaps in risk assessments for eating and drinking, pressure care, weight management and oxygen.
- Effective?
- Requires improvement
- People’s food and drink records and weight monitoring were not reliable enough. Staff training had gaps, referrals were not always timely, and the home did not always follow the required process for restrictions and best-interest decisions.
- Caring?
- Requires improvement
- Staff did not always communicate respectfully or understand people’s communication needs. Inspectors saw that dignity was protected in some situations, but people were not always encouraged to maintain their independence.
- Responsive?
- Requires improvement
- Care plans and the environment were not sufficiently personalised. There were no regular activities, and people were not always given choices about where or with whom they ate.
- Well-led?
- Requires improvement
- Management systems and audits did not identify all the problems found by inspectors. The manager was approachable and had improvement plans, but leadership, delegation and quality checks were not consistent enough.
What inspectors found, April 2024
Rated Requires Improvement; inspectors found high-risk problems with medicines, staffing, records and person-centred care, with warning notices issued.
This was an unannounced inspection on 13 December 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines, training and management systems.
They found problems across all five areas. Medicines were not always stored or recorded safely. Staffing was not always enough, people’s weights and health risks were not monitored properly, and care plans did not always give staff the right guidance.
People were not always offered suitable choices at mealtimes and there were no planned activities. Inspectors also found concerns about privacy, communication, staff training and how the home checked the quality and safety of care.
The overall rating is Requires Improvement. The previous provider was rated Good in 2019. The provider was asked for an immediate action plan, and the CQC issued warning notices for safe care and treatment and good governance.
Complaints were followed up
The manager kept oversight of complaints and responded in a timely way. Actions and outcomes were shared with staff.
“The registered manager had responded in a timely manner and outcomes and actions of complaints were shared with the team.” from the report
Some privacy was protected
Staff knocked before entering bedrooms and used private spaces for sensitive conversations.
“Staff we observed would knock on bedroom doors and seek permission to enter people's rooms.” from the report
Access to health professionals
People could receive support from district nurses and GPs when needed. Health professionals visited the home regularly.
“The home received regular visits from health professionals.” from the report
Action began during inspection
The provider and manager accepted feedback and took some immediate steps to address the concerns.
“The provider and registered manager took action on improvements straight away during the inspection.” from the report
Medicines were not safely managed
seriousCreams were not stored safely or dated when opened. A diabetes medicine had been out of stock for two weeks, and medicine records contained missing signatures.
“Topical creams were not stored safely, which posed a risk of inappropriate use from people living within the home.” from the report
Staffing levels were unsafe
seriousThere were times when one staff member was supporting 11 people at lunch, including three people who needed help with eating and drinking. The home had no staffing dependency tool to show that staffing levels met people’s needs.
“during our visit we observed times where 1 staff member was present where 11 people were eating their lunch.” from the report
Risks were not properly assessed
seriousSome people did not have suitable guidance for eating and drinking, pressure care, weight management or oxygen. One person was observed eating while lying down, which inspectors said created a high risk of harm.
“People with eating and drinking needs did not have assessments in place for staff to follow to ensure people were safe whilst eating and drinking.” from the report
People lacked activities and choice
needs fixingNo activities were taking place after the activities coordinator left. People were also not always offered a choice about where or with whom they ate.
“Activities did not take place during the day or night.” from the report
Quality checks missed problems
seriousAudits did not identify medicine shortages, old medicines mixed with new ones or outstanding fire safety actions. Personal emergency evacuation plans also lacked enough detail.
“Peeps in place did not hold sufficient detail to guide staff to safely evacuate people” from the report
- 01What has been done to make sure all medicines, especially creams and diabetes medicines, are stored, supplied and recorded safely?
- 02How many staff will be on duty at different times, and how do you assess whether staffing is enough for each person’s needs?
- 03What individual risk assessments and care guidance are now in place for eating and drinking, pressure care, weight monitoring and oxygen?
- 04What activities are currently available, and how are people’s interests and choices recorded?
- 05What has been completed to improve audits, fire evacuation plans and person-centred care plans?
This was an unannounced inspection covering all five CQC questions, including the premises, care provided, seven care records, all medicine records, staffing, training and management systems. This explanation was written from the published report of 20 April 2024 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 Comberton Nursing Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017GoodSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- May 2020
Registered with the Care Quality Commission on 1 May 2020.
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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