CQC report explained · a nursing home
What the CQC found at Camberley Heights Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, risks were assessed and managed, and inspectors found enough staff to meet people's needs. Medicines and infection control were managed safely, although incident logs were not always closed promptly or detailed enough.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff had training and support, people received suitable food and healthcare, and consent and best interest processes were in place.
- Caring?
- Good
- People and relatives described staff as kind and respectful. Inspectors saw staff protecting privacy and dignity, supporting independence and respecting people's choices.
- Responsive?
- Good
- Staff knew people's preferences and communication needs. There was a wide range of activities and complaints were investigated, but end of life care plans contained only basic information and were due to be developed further.
- Well-led?
- Good
- People and staff said the home was managed well, with a positive atmosphere and regular quality checks. Some care records needed updating and continual review, and an action plan was in place.
What inspectors found, December 2022
Pembroke House is rated Good; inspectors found safe, kind and personalised care, with some records and staffing arrangements needing attention.
Inspectors visited on 21 September and 9 November 2022. Both visits were unannounced. They spoke with people living there, relatives and staff, observed care and checked care, medicines, recruitment and management records.
People said they felt safe and treated with kindness. Inspectors found enough staff to meet people's needs, safe medicines systems, good infection control and suitable checks on risks. Staff supported people's choices, privacy, communication, health needs and activities.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The inspection was prompted by information about safe care, but inspectors found no evidence that people were at risk of harm from that concern. Some incident records, care records and end of life planning needed further improvement.
People felt safe
People told inspectors they felt safe, and staff understood how to recognise and report abuse or other concerns.
“People told us they felt safe living at Pembroke House.” from the report
Kind and respectful care
Staff treated people with kindness and protected their privacy, dignity and independence.
“We saw staff were careful to protect people's privacy and dignity.” from the report
Good activities and relationships
People helped shape the activities programme. Inspectors saw people enjoying activities, and staff offered one-to-one alternatives when needed.
“The activities we observed were well attended and approached with enthusiasm by everyone involved.” from the report
Strong management checks
Managers used audits, surveys, observations and action plans to monitor the service and respond to shortfalls.
“Quality assurance process were in place to monitor the service people received.” from the report
Agency staff consistency
minorAgency staff were used to cover vacancies. Staff said temporary workers did not always know people well, although they worked alongside permanent staff and their skills were reviewed.
“Staff told us this could be difficult due to having to give regular guidance as new agency staff did not always know people well.” from the report
Incident records
needs fixingIncident logs were not always closed promptly and sometimes lacked detail. The provider had identified this and was taking steps to improve recording.
“However, the incident logs were not always promptly closed and on occasions lacked detail.” from the report
Care records needed updating
needs fixingSome records did not fully reflect the latest information and needed continual review. Audits had identified this and an action plan was in place.
“However, some records were in need of updating and continual review.” from the report
- 01How are you reducing your use of agency staff, and how do you make sure temporary staff understand my relative's needs?
- 02What extra checks are now in place for the electronic medicines system, following the errors identified when it was introduced?
- 03Have all care records been updated, and how often are they reviewed when a person's needs change?
- 04How are you improving the detail in end of life care plans and involving relatives in those discussions?
- 05How do you make sure incident logs are closed promptly and contain enough detail to show what action was taken?
This was an unannounced inspection covering all five key questions and infection prevention and control, with a return visit at night after information about possible safe care risks. This explanation was written from the published report of 16 December 2022 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, August 2018
Rated Good; inspectors found safe, kind and personalised care, with medicines systems already being improved.
The inspection was unannounced and took place on 22 June 2018. Inspectors observed care, spoke with people, visitors, staff and managers, and reviewed care plans, medicines records, risk assessments, complaints and audits.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably checked staff, detailed care plans, safe medicines arrangements, kind staff and a wide range of activities.
The home was clean and well maintained. People were supported to make choices, stay independent, keep in touch with family and friends, and access health professionals. The report also records that the manager had identified medicines management as an area for improvement and had started an action plan.
Enough staff
Inspectors found enough skilled staff for people to receive care without waiting. Staff said they did not need to rush people.
“Sufficient skilled staff were deployed which meant people did not have to wait for their care.” from the report
Kind and respectful care
Staff spent time with people, knew their preferences and treated them with kindness. Privacy and dignity were respected.
“People were cared for by staff who showed them kindness and spent time getting to know them.” from the report
Personalised support
Care plans gave staff detailed guidance about people's needs and preferred ways of receiving care. Plans were reviewed monthly or more often when needed.
“Care plans contained detailed information regarding people's care needs and how they preferred their support to be provided.” from the report
Activities and independence
People could choose from activities linked to their hobbies and interests. Staff also supported people to continue activities in the community and remain independent.
“People had access to a varied activity programme which was designed around their needs, hobbies and interests.” from the report
Open management
Inspectors found a positive culture and regular checks on the quality of care. The home acted on people's suggestions.
“There was a positive culture throughout the service and staff understood the ethos of the organisation.” from the report
Medicines systems were being improved
minorThe manager had identified that medicines management systems needed to improve. An action plan and a group involving the GP and pharmacy had led to improvements, but this is an area families may want to check.
“For example, the registered manager had identified that medicines management systems needed to improve.” from the report
- 01What improvements have been made to medicines management since the action plan and steering group were introduced?
- 02How many permanent staff are normally on duty for the person's needs, and how would the home cover unexpected staff gaps?
- 03How would you assess and update my relative's care plan if their health, mobility, nutrition or emotional needs changed?
- 04What activities are currently available for someone with my relative's hobbies, interests or dementia needs?
- 05How would you involve my relative and our family in decisions where they may lack capacity?
This was an unannounced first inspection covering all five key questions, including the premises and care provided; there were no previous ratings to carry over. This explanation was written from the published report of 9 August 2018 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 Camberley Heights Care Home
2 rated inspections over 4 years: the service has held its Good rating throughout.
- December 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017
Registered with the Care Quality Commission on 6 June 2017.
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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