CQC report explained · a nursing home
What the CQC found at Pemberley House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely or given as prescribed. Recruitment checks, fire safety and some environmental safety measures were also not always adequate.
- Effective?
- Requires improvement
- Needs assessments were generally broad and regularly updated, but food texture guidance and some clinical and mandatory training were not up to date.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw patient, compassionate interactions, with people's dignity, choices and privacy respected.
- Responsive?
- Requires improvement
- Care plans were not always personalised or detailed enough. Activities and one-to-one social support were limited, although complaints were recorded and investigated.
- Well-led?
- Requires improvement
- Quality checks did not always identify or address safety and record-keeping problems. Staff described communication difficulties and a blame culture between some managers and staff.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found kind care, but medicines, recruitment checks, safety systems and activities needed significant improvement.
Inspectors visited the home without notice on 25 and 31 August 2022. They observed care, mealtimes, medicines and staff interactions. They spoke with people, relatives, staff and managers, and reviewed care plans, medicines records, training, audits and other documents.
The home was caring, clean and tidy. Staff were patient, compassionate and knew people well. However, inspectors found medicines were not always given as prescribed, some recruitment checks were missing, and fire and building safety were not always managed properly.
Care plans were not always personal or complete. Activities were limited, especially for people who needed one-to-one support. Some staff training was out of date, and quality checks did not always find or fix problems promptly. The overall rating and four of the five question ratings were Requires Improvement. Caring was rated Good.
Kind and respectful care
People and relatives said staff were kind and caring. Inspectors saw staff treating people with dignity and respect, and supporting their choices and independence.
“We observed staff interactions with people which showed people were treated with kindness, compassion, dignity and respect.” from the report
Individual risk assessments
Inspectors found that risks to people's individual health, safety and wellbeing were appropriately assessed, with care plans to guide staff.
“Risks to individual health, safety and wellbeing were appropriately assessed and there were care plans in place to support staff in managing these risks.” from the report
Infection prevention
Inspectors were assured that the home had suitable arrangements for preventing and managing infection outbreaks, including safe use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Learning from incidents
Incidents were reviewed for patterns, care plans were updated when needed, and learning was shared with staff.
“Learning from incidents was shared at team meetings with staff.” from the report
Complaints process
Complaints were recorded, investigated and responded to under the provider's policy. Most people and relatives felt able to raise concerns.
“Complaints had been recorded and responded to in line with the provider's policy.” from the report
Medicines were not always safe
seriousSome people ran out of medicines or did not receive them at the prescribed times. Records, storage, expiry checks and instructions for some medicines were also not reliable.
“The provider was not ensuring people received their medicines as prescribed.” from the report
Fire and building safety
seriousInspectors found problems including damage near a sprinkler head, holes affecting smoke protection, non-compliant fire doors and weak evacuation drills. Some issues were fixed after the inspection.
“Fire evacuation drills were not robust.” from the report
Recruitment checks
seriousNot all staff, including agency workers, had the required checks before being employed or deployed at the home.
“Not all staff, including agency workers, had the appropriate checks before being employed or deployed in the service.” from the report
Incomplete records and quality checks
seriousAudits did not always find problems, and some records contained old, missing or inconsistent information. This could increase the risk of mistakes in care.
“Some parts of this were not effective, such as the audit of window restrictors, which had not identified their non-compliance, even though this was known.” from the report
- 01What has been changed to make sure every medicine is given at the prescribed time and recorded correctly?
- 02What checks now confirm that all staff and agency workers have completed the required pre-employment checks?
- 03What repairs and fire safety improvements have been completed, and how are evacuation drills now tested?
- 04How will you provide regular, personalised activities and one-to-one time for people who cannot join group activities?
- 05How are care plans, food texture information and quality audits checked for accuracy and kept up to date?
This was an unannounced inspection covering all five CQC key questions, including infection prevention and control measures. This explanation was written from the published report of 30 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.
Every inspection of Pemberley House
Each visit the CQC has published, newest first, back to the day the home was registered.
- December 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2019
Registered with the Care Quality Commission on 28 August 2019.
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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26 live-in carers within about an hour of Hampshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
“I cannot recommend Prisca highly enough, she is one in a million.”
“He stayed with her throughout the pandemic, refusing to visit his own family, who lived nearby, to reduce the risk of infection.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.