CQC report explained · a nursing home
What the CQC found at Camelot Care Homes Ltd
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Camelot Care Homes Ltd is rated Requires Improvement overall, with Inadequate leadership, and remains in special measures; inspectors found kind care but serious gaps in risk management, care records and medicines.
This was an unannounced follow-up inspection on 6, 7, 9 and 10 February 2023. Inspectors spoke with people, relatives, staff and a visiting professional. They reviewed care plans, medicine records, incidents, complaints, staff records and audits, and inspected the home.
The home had improved since the previous inspection and its overall rating rose from Inadequate to Requires Improvement. Staff were generally kind and respectful, the home was cleaner, staffing levels were sufficient, and complaints were managed better.
However, inspectors found risks that had not been assessed, including distressed behaviour, choking risks and environmental hazards. Medicine records, food and fluid monitoring, care planning and daily records were not always accurate or complete. Quality checks had failed to identify these problems, so the well-led rating remained Inadequate.
The home remained in special measures. The provider was still in breach of regulations about person-centred care, safe care and treatment, safeguarding and good governance. CQC required an action plan and said it would continue to monitor the home with the local authority.
Kind and respectful care
Inspectors saw staff being kind, respectful and attentive. People and relatives were complimentary about the staff.
“Interactions observed were kind, respectful and attentive.” from the report
Clean surroundings
The home was cleaner than at the previous inspection. Bedrooms and shared areas looked clean and smelt fresh, with some new flooring.
“People's bedrooms and communal areas looked clean and smelt fresh.” from the report
Staffing and training
There were enough staff for the number of people living at the home. New recruitment meant the home was fully staffed and no agency staff were being used.
“New staff had been recruited, which meant the home was fully staffed. No agency staff were being used.” from the report
Improved complaints handling
Complaint records were more organised and showed the action taken. People and relatives said they felt able to raise concerns.
“Documentation regarding complaints which had been received, was more organised, and demonstrated the action taken to ensure a resolution.” from the report
Unassessed risks
seriousSome people's distressed behaviour had no written risk assessment or staff guidance. Other risks included unsuitable food for someone needing a pureed diet and unsecured hazardous areas.
“Some people displayed distressed behaviour, but there was no written risk assessment or guidance for staff to minimise or de-escalate any distress.” from the report
Medicine errors and incomplete records
seriousAn insulin dosage was changed without written prescriber authorisation. Allergies and handwritten changes were not always recorded or checked correctly.
“Staff had changed the dosage of one person's insulin on the medicine administration record, without the prescriber's written authorisation.” from the report
Weak management checks
seriousAudits and management checks did not identify serious problems already present in care records, medicine records, wound care and repositioning records.
“Auditing systems had not identified shortfalls in the safe management of people's medicines.” from the report
Incomplete care planning
seriousCare plans did not consistently explain how to support people experiencing distress, hallucinations, anxiety or wounds. This meant staff might not respond consistently or safely.
“Failing to have effective care planning in place did not ensure people received care that met their needs or preferences.” from the report
Food and fluid records
seriousRecords did not always give enough detail about food, snacks or fluid reviews. This made it harder to identify risks such as weight loss or malnutrition.
“Not maintaining accurate monitoring records of malnutrition or hydration, placed people at risk of harm.” from the report
Safeguarding records
seriousMultiple bruises on one person had not been recorded or investigated. The report said this did not protect the person from possible harm or abuse.
“There was no record of the bruises within the person's care records and an incident report had not been completed.” from the report
- 01What written risk assessments and staff guidance are now in place for people who become distressed or show challenging behaviour?
- 02How are medicine changes, allergies and handwritten instructions checked and authorised before medicines are given?
- 03How do managers check that food, fluid intake, repositioning, wound care and daily support are recorded accurately?
- 04What action has been taken to secure hazardous areas and remove other environmental risks identified by the inspection?
- 05What progress has been made against the action plan, and when will the provider's registration condition and special measures be reviewed?
This was an unannounced follow-up inspection of the care home after earlier enforcement action; inspectors reviewed all five key questions and checked progress against the previous inspection findings. This explanation was written from the published report of 25 April 2023 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, November 2022
Overall rating remains Inadequate and the home is in special measures; serious safety and management problems were still found.
This was an unannounced targeted inspection on 29 September 2022. Two inspectors spoke with two people and eight staff, toured the home, and checked maintenance and management records. They focused on a previous warning notice about good governance and also checked infection control.
Some improvements had been made. The home was cleaner overall, staff used protective equipment correctly, fire escapes were clear, and food and fluid monitoring had improved. However, hot water was still dangerously hot in some places, a fire exit needed a key, some hazards were accessible, and food storage and electrical safety checks were not reliable.
The inspectors found continued breaches of Regulations 12 and 17. This targeted inspection did not review every part of the five questions, so the ratings were not re-assessed. The previous overall rating remained Inadequate, and the home remained in special measures.
Food and fluid monitoring
Records and monitoring of people's food and fluid intake had improved. This reduced the risk of dehydration and malnutrition.
“Improvements had been made to the monitoring and recording of people's food and fluid intake.” from the report
Use of protective equipment
Staff were seen using masks, gloves, and aprons correctly. Protective equipment and hand sanitiser were available around the home.
“Staff were observed wearing masks, gloves and aprons correctly.” from the report
Some environmental improvements
Some areas had been repainted and flooring had been replaced with surfaces that were easier to clean. The environment was cleaner overall than at the previous inspection.
“Since our last inspection, we found the overall cleanliness of the environment had improved.” from the report
Staff discussions and learning
Staff said they had received more group supervision and individual meetings with their manager. This created more opportunities for discussion and shared learning.
“Staff told us more group supervision and individual meetings with their line manager had taken place.” from the report
Risk of scalds
seriousWater from some hand basins was excessively hot, including one measured at 62.2°C. A very hot water pipe in a shower room was also not made safe.
“The temperature of the water therefore, significantly increased the risk of people being scalded.” from the report
Fire escape access
seriousNew fire escape doors required a key to open them. This could delay people leaving the building during an emergency, and fire risk actions were not completed within the recommended timescales.
“This prevented a timely exit in the event of an emergency, and increased the risk of harm.” from the report
Infection control and cleanliness
seriousUsed protective equipment was not always disposed of safely. Some areas were still visibly unclean, including stained carpets, dust, and debris in the kitchenette.
“Systems had not been established or embedded to make sure people were consistently protected from the risk of infection from their environment.” from the report
Access to hazards
seriousThe sluice and kitchen doors were sometimes left open, allowing access to equipment and an urn. The home also lacked a complete list to ensure all electrical appliances were tested.
“This included the sluice and the kitchen doors, yet these were left open at times, giving people access to equipment and an urn.” from the report
Food storage
needs fixingSome food was not covered or dated after opening. The refrigerator appeared too warm and its thermometer was reportedly broken, so safe storage temperatures could not be reliably checked.
“This did not ensure accurate monitoring to ensure safe storage of food.” from the report
- 01Have the dangerously hot hand basins and exposed hot water pipe now been made safe, and how are temperatures checked?
- 02Can you show us that the fire escape doors can be opened quickly without a key and that all fire risk assessment actions are complete?
- 03How do you ensure used protective equipment is disposed of safely and that all areas remain clean?
- 04How do you prevent people from entering the kitchen and sluice, and how do you check that all electrical appliances have been tested?
- 05How do you check refrigerator temperatures and ensure opened food is covered, dated, and stored safely?
This was a targeted inspection of specific concerns under Safe and Well-led, plus infection control; it did not assess the whole of either key question or the other three key questions, so the previous ratings carried over. This explanation was written from the published report of 26 November 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.
Every inspection of Camelot Care Homes Ltd
9 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- November 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015
Registered with the Care Quality Commission on 19 January 2015.
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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