Symonds House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. Whilst there was no harm noted to people, there was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Whilst staff listened to concerns about safety they did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

When incidents and accidents had occurred over the weekend, these had not always been reported to the registered manager. Staff had recorded accidents and incidents in care notes. Whilst we noted no harm had come to people and appropriate action had been taken to ensure people were safe and well cared for.

On our second visit to the service, we found that the registered manager had put in place flash meetings which took place on the weekends to ensure any incidents or accidents are recorded. This ensures the information is made available to the registered manager and that any further action and learning is taken forward.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager worked closely with commissioners of services to ensure systems were in place to support people moving to the service in the future. A professional from the local authority confirmed they had a good working relationship with the registered manager.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The staff did not always share concerns quickly and appropriately.

We noted that unexplained bruising and skin tears were recorded in people’s care notes although the registered manager confirmed that they had not seen these reports. The incidents appeared to have not been reported as no meetings were held over the weekend with those in charge of the shifts. The registered manager has put in additional processes to ensure that they are informed of incidents that occur over the weekend. It was unclear from the care records whether these incidents had been reported to the local safeguarding team for investigation or to the CQC, as required. The registered manager said it was their mission to put in place a process to ensure accident and incidents are reported and forms are signed off in the future.

People who could communicate verbally confirmed that they felt safe living at Symonds House. One person said, “I have never seen anything that concerned me about the staff.” One relative told us, “Staff are around all the time to keep an eye on them.”

Staff confirmed they had received safeguarding training and confirmed they knew how to raise safeguarding concerns, although we noted that not all had been reported to the registered manager. Staff confirmed that any learning from safeguarding incidents were discussed at team meetings.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was not always safe, supportive and enabled people to do the things that mattered to them.

On our first visit to the service, that whilst risks had been identified not all of them had been fully addressed to provide a fully safe environment for both people and staff. The window restrictors that were in place did not comply with safety standards. At our second visit we saw that the provider and the registered manager had addressed our concerns and all the window restrictors had been replaced to comply with British standards. This ensured that people were safe.

People’s risks were assessed before and after their admission. These included risks associated with living with dementia as well as other medical conditions.Suitable management plans were developed to ensure risks were mitigated.

The provider did not always detect and control potential risks in the care environment. However, they did ensure equipment, facilities and technology supported the delivery of safe care.

During our first visit the provider and registered manager had not identified as part of their audits, that the window restrictors did not comply with the British Standards. By our second visit the provider had replaced all of the window restrictors which are now compliant.

The service is a grade 2 listed building and as such it was proving difficult to update the environment. People and their relatives made comments such as. “I am happy with it because I have got all of this space up here and I am out of the way. It isn’t very modern, but it suits me”, “It is not the best building, but it is better than any in Cambridge. [Family member’s] room is fine”, “The building is rubbish, but the care is good. I am more concerned with [family member] having good care than the state of the building” and “The home itself is a bit tatty looking, but the grounds are nice.”

Following a recent fire inspection, the provider is in the process of replacing all the fire doors following the recommendations made.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide care that met people’s individual needs.

The provider assessed staffing levels required using a dependency tool. Overall, during our visits, we found staff were able to respond effectively to people’s needs. The provider had amended staffing numbers due to fewer people living at the service.

People and relatives generally felt that there were enough staff. Comments included: “I think they do have enough staff but sometimes they have agency staff, and they are not always familiar with the tasks which causes frustration as I have to explain everything.” “They seem to have enough staff although there seem to be less at weekends. They have to have some time off. The only impact it has is that I might have to wait longer to be let in.” “I think it does vary about the level of staffing but there is always someone in the lounge. It doesn’t seem to affect [family member] though. I can always get hold of someone if I need them.”

There were arrangements in place to ensure staff completed induction training, kept up to date with mandatory training and staff received supervision from their line manager.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had policies and procedures in place to reduce the risk to people and staff catching and spreading infections.

Staff had sufficient supplies of personal protective equipment (PPE). They received training to help them maintain good standards of infection control. Staff told us they followed procedures for the use and disposal of their PPE. People and relatives also confirmed staff followed safe infection control practices. A relative commented, “Staff seem to keep things pretty clean.”

The provider did not always ensure medicines were managed safely due to the concerns found.

The registered manager had not ensured staff complied with the medication policy to ensure people received their medicines as intended. We reviewed 2 audits for September and October 2025, although we noted that the medication policy states a weekly audit of medicines is undertaken which includes balances for tablets and liquids. The registered manager told us they would review the processes and policy to ensure it reflects the practice that is in place. Without regular weekly audits, the service may not promptly identify issues with medicine balances and take appropriate actions.

On our second visit we found there was a discrepancy between the number of tablets in the box and the number of tablets recorded within the electronic medication administration records (E-mar) for two people. An audit was conducted following our visit and the discrepancies were identified and found to be the recording where two people had chosen to decline their medication.

Staff had received training, and their competence was assessed regularly. Staff were able to explain how they supported people with their medicines and how they escalated any concerns. Staff engaged with other healthcare professionals and took part in regular multidisciplinary meetings to review people’s medicines.

People and their families commented on medication administration, and these included “The nurses give me my medication, and I also take my own vitamins. I was on a medication that I didn’t want to take anymore, and they contacted the GP and found a solution for me. If I am in pain, then I can get pain relief.” And “We haven’t had any problems with the medication, and they tell me if they need to review anything.”