CQC report explained · a nursing home
What the CQC found at Soham Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people’s risks were assessed and monitored, medicines were managed safely, safeguarding systems were understood and infection control arrangements were effective. The staffing tool showed a shortfall in available staffing hours, although inspectors found enough trained staff to meet nursing and care needs at the time.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found that the registered manager and staff understood their roles, used audits to monitor quality and acted on issues. People and relatives were involved in care decisions and could raise suggestions or concerns.
What inspectors found, March 2023
Soham Lodge is rated Good; inspectors found safe, respectful care and better management, but noted a shortfall in staffing hours.
This was an unannounced, focused inspection. Inspectors visited on 13 February 2023 and 02 March 2023. They spoke with people, a relative, staff and a visiting health professional, and reviewed care records, medicines records, recruitment files and management checks.
The home was rated Good for Safe and Well-led. Inspectors found that people’s risks were assessed, medicines were given as prescribed, infection control was effective and there were enough suitably trained staff to meet nursing and care needs. Staff knew people well and respected their choices.
The dependency tool showed a shortfall in staffing hours, and the home was recruiting. The provider also corrected the display of its previous CQC rating on its website during the inspection. The overall rating improved from Requires Improvement at the previous inspection to Good.
Care matched people’s needs
Staff knew people’s needs, wishes and preferences. Care plans and records were updated when people’s needs changed.
“People's care plans and records were reviewed and updated when changes occurred.” from the report
Safe staffing processes
The home used a dependency tool to help calculate staffing needs. Inspectors found enough suitably trained staff to meet people’s nursing and care needs during the inspection.
“There were enough suitably trained staff to meet people's nursing and care needs.” from the report
Medicines were managed safely
Staff competencies were checked, medicines were audited and inspectors found that people received their medicines as prescribed.
“People had no concerns with how they were supported to take their medicines.” from the report
Open management
People were involved in decisions and could give feedback through meetings and surveys. Management used audits and incident reviews to identify improvements.
“It is a very open culture here and you are not afraid to speak up.” from the report
Staffing hours shortfall
needs fixingThe staffing tool showed fewer staffing hours than the tool said were needed. The manager said the home was recruiting, so families should ask what has changed since the inspection.
“However, the dependency tool used did show a shortfall in staffing hours available.” from the report
Website rating display
minorThe previous CQC rating was not clearly displayed on the website when inspectors checked it. This was corrected during the inspection.
“At this inspection we found that the provider was not conspicuously displaying the rating from their last CQC inspection on their website.” from the report
Survey response rate
minorThe manager recognised that more people and relatives could respond to service surveys. The report does not say that this affected the care provided.
“The registered manager was aware that the return response rate on the surveys could be improved.” from the report
- 01How many staffing hours did the dependency tool identify as needed, and how many staff hours are currently available?
- 02Has the recruitment mentioned in the report been completed, and how does the home cover staff shortages?
- 03What are the current ratings for Effective, Caring and Responsive, which were not inspected during this visit?
- 04How does the home check that people’s care plans are updated when their needs change?
- 05How are survey feedback and residents’ meeting suggestions acted on?
This was an unannounced focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 16 March 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, December 2020
Inspected but not rated; inspectors found good infection controls during a targeted COVID-19 review.
This was an unannounced, targeted inspection on 20 November 2020. It looked only at infection prevention and control during the COVID-19 pandemic.
Inspectors found that essential visitors were screened and given protective equipment. Staff used full protective equipment, and the home changed care and medicine routines to reduce infection risks.
The building was clean and uncluttered. Inspectors were assured that the home had suitable arrangements for testing, admissions, shielding, hygiene and managing outbreaks.
The home was inspected but not rated. This means the visit did not provide an overall CQC quality rating or assess all five areas of care.
Visitor screening
Essential visitors were screened on entry and required to use protective equipment.
“Any person entering the building had their temperature taken, completed a health questionnaire and wore full personal protective equipment (PPE) including a face visor.” from the report
Use of protective equipment
Staff used full protective equipment when supporting people, whether they had tested positive or negative for COVID-19.
“People were supported by staff in full PPE, whether that person was COVID-19 positive or negative.” from the report
Infection control routines
The home changed the order of care and medicine rounds to reduce the risk of spreading infection between people.
“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.” from the report
Clean environment
Inspectors saw communal areas and bathrooms being cleaned, with frequently touched surfaces disinfected.
“The building was clean and free from clutter.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection control arrangements are currently used when essential visitors enter the home?
- 02How are staff and residents tested, and what happens when someone has a positive result?
- 03How are care visits and medicine rounds organised for people with different COVID-19 results?
- 04How are communal areas, bathrooms and frequently touched surfaces cleaned and disinfected?
- 05What arrangements are in place to prevent or manage an infection outbreak?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated overall. This explanation was written from the published report of 9 December 2020 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 Soham Lodge
8 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Inspected but not ratedSafe: Requires improvementWell-led: Requires improvement
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 8 August 2012.
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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