What the CQC found at Camberwell Lodge

Most people said staff treated them with kindness, dignity and respect. Inspectors observed positive interactions and found that people's choices and preferences were recorded.

“Most people told us they were treated with respect and dignity from kind and caring staff.” from the report

Care plans included people's life history, hobbies, preferences and communication needs. Daily records helped staff understand how people responded to their care.

“Care plans contained a good level of detail to ensure staff would understand people's personal preferences in all aspects of their care and support.” from the report

The home offered communal activities, one-to-one support and trips outside the home. Inspectors saw technology being used to provide suitable stimulation.

“The home had wellbeing coordinators who devised daily communal activities and provided one-to-one interaction for people who could not join these.” from the report

People were supported to record their wishes for future care, pain relief, funeral arrangements and resuscitation decisions. The home also worked with the local hospice service.

“People shared their end of life wishes with staff and these details were recorded on their advanced care plan.” from the report

Staff received induction, ongoing training and supervision. Inspectors found staff had training in areas including safeguarding, medicines and end of life care.

“Staff were supported through an induction and ongoing training and supervision.” from the report

Pressure care records were not always up to date, dressings were not always changed as recommended, and 13 mattresses were set incorrectly. This increased the risk of skin breakdown.

“In total we found 13 people's mattresses were incorrectly set which meant they were exposed to greater risk of skin breakdown.” from the report

Some medicines prescribed when needed did not have enough instructions. Stock records did not always match actual stock, some administration records were unsigned, and topical creams were not recorded clearly.

“Medicines were not always managed safely.” from the report

Staffing levels sometimes fell below the home's own calculated minimum. Call bell records showed many waits of more than five minutes, including some of more than 30 minutes.

“The call bell records for November, December and January showed many occasions when people were waiting longer than 5 minutes and some instances where people waited over 30 minutes.” from the report

Audits and checks failed to identify or fix several problems. An issue with mattress settings had been identified in October but remained until the inspection in December.

“There were a range of quality assurance audits and checks in place, however they had not identified all the issues we found with pressure care, medicines and staffing and call.” from the report

Although complaints were investigated under the home's policy, some family members were unhappy with the responses. Investigations did not identify the staffing problems inspectors found.

“Some people told us they were not happy with how their complaint had been dealt with as not all aspects of their complaint were fully investigated.” from the report

The provider did not notify CQC promptly about an incident involving the police and had not notified the relevant family member at the time. The notification was submitted after inspectors raised it.

“They had failed to notify us of an incident involving the police.” from the report