Archived: Camberwell Green

Updated 11 December 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 16 and 30 September 2015 and was unannounced. Four inspectors and a pharmacist inspector carried out the inspection.

Before we visited the home, we spoke to the safeguarding and commissioning teams from the local authority. We also checked the information we held about the home. This included notifications we had received. A notification is information about important events, which the registered person is required to send us by law. We contacted other people involved with the home including a specialist nurse and an environmental health officer.

We made general observations when we were in the home. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We reviewed the information we held about the home including records of notifications sent to us. We spoke with 10 people who lived at the home and four relatives. We spoke with the registered manager and with eight other members of the staff team including nurses, care staff, catering and ancillary staff.

We looked at personal care and support records for eight people and medicines records for people throughout the building. We looked at other records relating to the management of the service, including policies and procedure documents and staff rotas. On the second day we visited, some records were unavailable because the manager was not present. We asked the registered manager to send us audit reports and we received them soon after our visit.

Updated 11 December 2015

Camberwell Green provides nursing care for up to 55 older people, some of whom have dementia. At the time of the inspection there were 40 people living there.

The home was last inspected on 26 February and 12 March 2015. At that inspection we found two areas which needed improvement. One concerned a damaged fire door and the other was about ineffective monitoring systems. The management systems remained a concern at this inspection and we are considering the action to take.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

People did not receive safe care and treatment due to poor medicine management. People were given medicines at times when the GP had not prescribed them and one person received medicines which records stated they were allergic to. There were too few nursing staff to provide care safely for people. This led to medicines being administered late.

People whose health conditions put them and others at risk of harm were not adequately supported through assessments and planning to manage the risks.

People who were at risk of dehydration did not always receive enough fluid to maintain their health and well-being.

Staff who were new to the service did not receive an adequate induction to provide care which reflected people’s needs.

We saw examples of staff being caring towards people, but we also observed staff treating people with a lack of respect and regard for their dignity.

The manager and staff knew their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty of Safeguards.

Staff did not know people well enough to be able to provide a responsive service. There were opportunities for people to complain and make their views known to the manager and the provider. The registered manager investigated complaints and made improvements when appropriate.

Checks and audits were carried out but did not lead to improvements in the care people received. The CQC was not informed about events that the registered person is required to tell us about.

We identified breaches of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to: safeguarding people from abuse and improper treatment, safe care and treatment, meeting nutritional and hydration needs, good governance and staffing. There was also a breach of a regulation of the Care Quality Commission (Registration) Regulations 2009. This related to the notification of incidents. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special measures'. The service will be kept under review and will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.