Cambridge Court Care Home

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 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. There was an increased risk 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 promote a proactive and positive culture of safety based on openness and honesty. Lessons were not consistently learned or used to drive improvement in practice.
Accidents and incidents were recorded, and individual events were reviewed, with some action taken to reduce risks to the person involved. However, there was insufficient analysis of incidents to identify themes, patterns and trends, which limited opportunities to mitigate risks more widely.
We found there was little effective analysis of behaviour monitoring tools, such as Antecedent, Behaviour, and Consequence (ABC) charts. This meant triggers and patterns of behaviour were not consistently identified, reducing opportunities to understand behaviours and implement proactive strategies to minimise risks to people.
Although staff understood how to record incidents and accidents, oversight systems were not robust enough to ensure learning was embedded and improvements were sustained.
 

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 provider worked well with other health professionals to ensure continuity of care. One health professional we spoke with told us, “They refer appropriately and always follow instructions and advice. They refer to other services as required.”
 

The provider demonstrated an understanding of safeguarding responsibilities and appropriately reported concerns to the local authority. Staff had received safeguarding training and were able to describe the actions they would take to protect people from harm.
Relatives we spoke with told us they felt their family members were safe. One relative told us, “Yes, I feel [person] is safe here”
 

Risks were clearly recorded with actions required to mitigate risks however, they were not always updated in a timely manner following changes in people’s needs. For example, one person living with epilepsy did not have a specific risk assessment in place, however they did have an epilepsy care plan. Within the care plan, it stated under 'Actions' that the person spent most of their day in the lounge. This information was not accurate, as their end-of-life care plan and our observations confirmed that the person was being nursed in bed.
Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Relatives told us people were safe and risks were managed well. Relatives reported how risks to their family member had been reduced due to the actions by staff. For example, one person’s relative we spoke with told us, “[Person’s] swallowing reflex wasn’t very good so they [staff] got him on liquid meds, [person’s] diabetic so it’s important they get their meds, [person’s] sugars are more stable now as they take the liquid.”
 

The provider did not always detect and control potential risks within the care environment. They did not ensure equipment, facilities and technology supported the delivery of safe care.
We identified areas within the home that required attention. This included some fire doors where gaps underneath meant they would not effectively contain fire in the event of an incident. This appeared to be an ongoing risk, as the provider shared evidence that previous doors had been repaired. We discussed this with the registered manager, who assured us immediate actions were being taken to address these issues.
Concerns had been identified within the fire risk assessment regarding the compartmentation of a staircase that was being used as a fire escape. The provider took action to mitigate this risk by removing the fire exit signage and replacing it with a ‘staff only’ sign. This measure prevented the door from being used as a fire escape, as an alternative compliant escape route was available.
 

The home was arranged across three floors, each with communal areas; however, people were mainly observed spending time in the basement lounges rather than making use of the other communal areas on each floor. One person told us, “I wake up early and they get me washed and dressed and I have to come down here which is okay, it's always busy here.”
The registered manager explained that this approach was used to support the effective deployment of staff across the home.
Views from staff regarding staffing levels were mixed. Some staff felt additional staff would support more timely care. One staff member said, “We would benefit from extra staff, we have brought it up, but we were told it is to do with cost.” However, another staff member told us, “There is enough staff on shift.”
One person raised concerns about staffing levels at night, stating, “I don’t feel safe at night because if there was a fire, I’d have to rely on the staff to get me out. There’s not a lot of staff on at night so it’s a worry.”
The registered manager told us the dependency tool used to calculate staffing levels was effective and that staffing levels were kept under regular review. While staffing levels were generally maintained, the deployment of staff did not always support people accessing all areas of the home in line with their preferences.

Staff had received training and had their competencies assessed when required to enable them to carry out their role effectively. The provider ensured staff were recruited safely by undertaking checks with the disclosure and barring service to ensure staff were recruited safely.

The provider did not always assess or manage the risk of infection. We observed domestic staff working hard within the home, and they told us there were enough staff to provide seven-day-a-week cover. We found some areas of the home required cleaning, as well as damaged walls and flooring. These issues could impact effective infection prevention and control (IPC) measures.
The provider was aware of the repairs required to support safe IPC practices and had an ongoing action plan in place.
 

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences.
Medicine administration was safe and well managed. Whilst there were some medicine errors this was clearly documented and action taken. Controlled drugs were safely stored, and effective systems were in place including twice daily checks. For people that required medication ‘as required’, the protocols in place were detailed and effectiveness of the medicine was routinely recorded. For people who required their medication to be administered covertly for example, hidden in food, this was clearly recorded with evidence of GP and pharmacy involvement. Topical creams were safely stored in locked boxes in people’s bedrooms and administered safely and records maintained.
Medication audits were undertaken regularly. All staff responsible for administering medicines had completed the required training and had their competencies assessed.
People had their medication reviewed regularly by appropriate health professionals including the GP.