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 at the prescribed times. Fire safety, hazardous storage and recruitment checks also had shortcomings, although individual care risks and infection control were generally managed appropriately.
- Effective?
- Requires improvement
- People's needs were assessed, but food texture guidance was out of date and some staff training, including clinical and mandatory training, was not current. Staff supported people with eating and drinking and referred people to healthcare services when needed.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw staff treating people with dignity, respect and compassion, and supporting their choices and independence.
- Responsive?
- Requires improvement
- Care plans were not always personalised or detailed enough. Activities and one-to-one time were limited, although complaints were investigated and people were supported to maintain relationships.
- Well-led?
- Requires improvement
- Audits and governance systems did not always identify or address problems promptly, and some records were inaccurate or out of date. Staff described a divide between managers and staff, including a blame culture.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found kind care, but serious problems with medicines, safety checks, staffing checks and management.
Inspectors visited without notice on 25 and 31 August 2022. They observed care, mealtimes, medicines and staff interactions. They spoke with people, relatives and staff, and reviewed care plans, medicine records, training records, audits and other documents.
The home was caring and staff were kind, patient and respectful. People were generally supported with their individual health and safety risks, and infection prevention arrangements were satisfactory. However, medicines were not always given as prescribed, some safety risks in the building were not managed properly, and recruitment checks were incomplete.
Care plans were not always personal or detailed enough. Activities were limited, especially for people who needed one-to-one support. Training, records and quality checks were not consistently up to date. The overall rating was Requires Improvement, with the Safe, Effective, Responsive and Well-led areas also rated Requires Improvement. Caring remained Good.
Kind and respectful care
People and relatives said staff were caring and kind. Inspectors observed patient, compassionate interactions and found that staff knew people well.
“We observed staff interactions with people which showed people were treated with kindness, compassion, dignity and respect.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infection, including the safe use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Individual risk assessments
People's individual health, safety and wellbeing risks were assessed, with care plans to guide staff. Equipment and water safety were also managed appropriately.
“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
Learning from incidents
Incidents were recorded and reviewed for patterns. Inspectors saw that care plans were updated after incidents such as falls.
“Learning from incidents was shared at team meetings with staff.” from the report
Medicines not always safe
seriousSome people ran out of medicines or did not receive them at the prescribed time. Records, storage, expiry checks and instructions for some medicines were not reliable, putting people at risk.
“We found that medicines were not always managed safely which placed people at risk of harm.” from the report
Building and fire safety
seriousInspectors found unsecured hazardous items, damaged fire safety features, non-compliant or propped-open fire doors and weak evacuation drills. Some issues were fixed after inspectors raised them.
“Issues related to fire safety had not been identified and appropriately managed.” from the report
Incomplete recruitment checks
seriousNot all staff, including agency workers, had the required checks before working in the home. This was a breach of the regulations.
“Not all staff, including agency workers, had the appropriate checks before being employed or deployed in the service.” from the report
Training gaps
needs fixingSome nursing, dementia, fire safety, safeguarding, mental capacity and infection control training was not up to date. Inspectors were not assured that nursing staff were always confident and competent for people's clinical needs.
“Some training, which reflected the needs of people being supported, was not regularly refreshed.” from the report
Weak oversight and records
seriousAudits did not always find problems, and some records were inconsistent or out of date. Staff also described poor support from senior staff and a blame culture.
“Governance processes were not always robust and did not identify and promptly address quality and safety issues.” from the report
- 01What has been changed to make sure every medicine is given at the prescribed time and recorded correctly?
- 02What has been done to fix the fire safety issues and make sure all staff practise a full evacuation?
- 03How do you now check that permanent and agency staff have completed all required pre-employment checks?
- 04What is the current plan for providing regular one-to-one activities and reminiscence, especially for people who cannot join group activities?
- 05Which staff training has been brought up to date, particularly clinical, dementia, fire safety and infection control training?
This was an unannounced inspection covering all five CQC questions, the care provided, the premises and infection prevention and control; the previous rating was Good, but this was the first inspection since a second legal entity registered for the service. 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.
What inspectors found, September 2017
Pemberley House was rated Good; inspectors found safe, kind and personalised care after major improvements under the new provider.
This was an unannounced inspection on 20 and 21 June 2017. Inspectors spoke with people living in the home, relatives, staff and health professionals. They reviewed care plans, medicines records, staffing, training and management records, and observed care and mealtimes.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, received medicines safely, and had enough staff to meet their assessed needs.
The report says the previous inspection in June 2016 found improvements were needed in most areas. The current provider took over in May 2017, and people, relatives and staff described significant recent improvements. Some work was still under way, including transferring care plans to the new system.
Improved staffing
Staffing levels had increased and records showed the planned staffing level was being provided. People and relatives said staff were less rushed and that there was more continuity.
“People and staff told us there had been a substantial reduction in the use of agency staff, which rotas confirmed.” from the report
Safe medicines
Qualified nurses administered medicines and their competence was checked. Records, storage, reviews and guidance for medicines taken when needed were found to be safe.
“People received their medicines safely. Only qualified nurses who had received appropriate training administered people's medicines.” from the report
Kind and respectful care
Inspectors saw staff taking time with people, explaining care and responding sensitively when people were upset or anxious.
“Staff took their time with people and did not rush or hurry them.” from the report
Activities and relationships
The home offered varied activities, including music, games, outings, exercise and gardening. People were also supported to build friendships and keep in contact with important people.
“The activities co-ordinator and staff organised a diverse range of activities for people including: art, craft, music, games, films, outings, exercises and gardening.” from the report
Listening and improvement
Managers sought views through meetings, surveys and other feedback. Inspectors found that concerns and feedback were used to make changes.
“The registered manager sought feedback from people, their families and staff, which they used to drive continuous improvement in the service.” from the report
Additional nursing cover
minorSome nurses said an additional nurse would be needed to support continued improvement in clinical care. The provider said it was reviewing the number of nurses deployed.
“Some nurses we spoke with told us that to ensure the continued improvement in the quality of clinical care being provided an additional nurse would be required.” from the report
Care plans still being transferred
minorThe provider was still moving all care plans onto its new system. The plans inspected contained the required information, but this change was not yet complete.
“At the time of inspection the provider was in the process of updating all of the care plans and converting them to their system, to make them more person centred.” from the report
- 01How many nurses are normally on duty on each shift, and has the need for an additional nurse been resolved?
- 02Has the transfer of all care plans to the new system been completed?
- 03How do you check that staffing levels continue to match residents' changing needs?
- 04How are relatives involved in reviewing and updating their family member's care plan?
- 05What changes have been made since this inspection to maintain the improvements described in the report?
This was an unannounced inspection of the overall quality of the home, covering all five CQC questions and providing ratings for each. This explanation was written from the published report of 19 September 2017 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Pemberley House
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017
Registered with the Care Quality Commission on 3 May 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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