CQC report explained · a residential care home
What the CQC found at Pemberton Fold
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 records, stock balances and storage temperature checks were not always reliable. Individual risks were not always recorded or managed clearly, although safeguarding systems, recruitment checks and premises safety checks were in place.
- Effective?
- Requires improvement
- Staff had relevant training, but some refresher training was overdue. People received support from health professionals and under the Mental Capacity Act, but records did not always reflect this fully.
- Caring?
- Good
- This question was not covered by this focused inspection.
- Responsive?
- Requires improvement
- Care plans did not always record people's preferences, declined care or individual risks. Activities, communication and end-of-life support were positive, and people and relatives said some care had improved.
- Well-led?
- Requires improvement
- Provider oversight and audits were limited, and records were inconsistent. A senior support team had begun providing training and management support, but important improvements were still outstanding.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found unsafe medicines management, incomplete risk and care records, and weak oversight.
This was an unannounced focused inspection. Inspectors visited on 2 and 8 August 2023, spoke with people, relatives and staff, and checked care plans, medicines records, recruitment files and quality checks.
The home had enough staff to meet people's needs, and people said they felt safe. Staff were kind and communicated well. Activities had improved, and end-of-life care was described as supportive and compassionate.
However, medicines were not always managed safely. Some risks were not recorded clearly, care plans did not always reflect people's preferences, and audits had not found or fixed problems quickly enough. The home remains rated Requires Improvement in Safe, Effective, Responsive and Well-led. It has had this rating for its last two inspections.
People felt safe
People told inspectors they felt safe, and staff knew how to recognise and report possible abuse. Call bells were answered in a timely way during the inspection.
“People we spoke with told us they felt safe.” from the report
Improved activities
The home had three activity co-ordinators and offered group and individual activities. People were supported to maintain relationships and take part in interests that mattered to them.
“The activities are pretty good. We play skittles in the garden when the weather is okay; there are reminiscence sessions, bingo, coffee mornings.” from the report
Compassionate end-of-life support
The home followed a recognised end-of-life programme and had a lead staff member for this area. Relatives could stay in an en-suite room when a person was nearing the end of life.
“The home had received thank you cards and messages for the compassionate end of life care provided to people.” from the report
Good infection controls
Inspectors were assured that the home had arrangements for preventing and managing infections, including safe visiting and the effective use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines were not reliably managed
seriousNot all staff who gave medicines had documented training or competency checks. Inspectors also found gaps in administration records, stock discrepancies and inconsistent temperature monitoring.
“We could not be assured that people had received their medicines as prescribed.” from the report
Individual risks were not recorded clearly
seriousElectronic risk assessments were too general and did not set out how to manage some people's individual risks. Two people bypassed locked doors, including one person who left the home and entered the community when it was unsafe.
“Risk assessments on electronic systems were generic; individual risks and measures to mitigate these risks were not documented.” from the report
Care plans lacked personal detail
needs fixingThe new electronic care plans did not always record people's preferences, when they declined care or the care actually provided. Inspectors were not assured that care was consistently person-centred.
“Care plans lacked detail, particularly regarding people's individual preferences for care.” from the report
Provider oversight was weak
seriousAudits and records were incomplete or ineffective, and the provider had not dealt with known shortfalls quickly enough. Support with the new electronic systems had also been delayed.
“Audit processes were poor, record keeping was inconsistent, and the provider had failed to address the shortfalls in a timely way.” from the report
Food temperature concerns
minorThree people told inspectors that food was not always hot when served. People were offered alternatives if they did not like the menu.
“Three people complained that the food wasn't always hot when it was served up.” from the report
- 01How have you checked that every member of staff who gives medicines is trained and has passed a competency check?
- 02How are medicines stock levels and storage temperatures now checked and recorded?
- 03How have you recorded and reviewed each person's individual risks, including risks of falls, leaving the home or accessing unsafe areas?
- 04How will you make sure electronic care plans include each person's preferences and record when care is declined?
- 05What provider-level audits are now taking place, and how do you check that problems are fixed promptly?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected, and the report says ratings for questions not inspected carry over from the last inspection. This explanation was written from the published report of 13 September 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, February 2023
Rated Requires Improvement; inspectors found kind care, but serious medicines and record-keeping problems created risks.
This was an unannounced inspection on 14 and 15 December 2022. Inspectors spoke with people, relatives, staff and managers. They reviewed care records, medicines records, staff files and management records.
People generally felt safe and were treated kindly. Staff were respectful and supported people's privacy, dignity, choices and independence. The home had safe recruitment checks, suitable training and access to health professionals.
However, medicines were not always managed safely. Care plans, food and fluid charts, weight records and checks of care tasks were not always complete or accurate. Activities were limited, and records did not show clearly that planned activities had taken place.
The overall rating was Requires Improvement. The five ratings were Safe Requires Improvement, Effective Requires Improvement, Caring Good, Responsive Requires Improvement and Well-led Requires Improvement. The rating had fallen from Good at the last inspection under the previous provider.
Kind and respectful care
Inspectors saw warm interactions, and people said staff respected their privacy, dignity and individual needs.
“We observed kind and caring interactions between staff and people.” from the report
Safeguarding
People were protected from abuse, and staff understood the signs of abuse and what action to take.
“People were protected from the risk of abuse and told us they felt safe living at the home; relatives confirmed this.” from the report
Staff preparation
Recruitment checks, induction, training and supervision were in place to help staff carry out their roles.
“Staff received induction, training and supervision to ensure they were skilled and competent to carry out their roles.” from the report
Health support
People could access several health professionals, and an on-site paramedic was available to help assess medical needs.
“People had access to a variety of medical and health related services, such as general practitioners, speech and language therapists, district nurses and dieticians.” from the report
Dementia-friendly environment
Clear signs, themed areas and personal belongings helped make the building easier to navigate and more personal.
“The environment was dementia friendly, with clear signage in all areas to help people orientate around the building.” from the report
Medicines safety
seriousStock checks found discrepancies that could indicate missed doses, wrong doses or recording errors. Guidance for some medicines given when needed was missing, and known problems had not been fixed promptly.
“Medicines were not always managed safely. We identified issues with record keeping, stock control and the timeliness with which identified medication issues had been addressed.” from the report
Incomplete care records
seriousSome care plans lacked important information, and daily records did not always show that planned checks and personal care had happened. This placed people at risk of harm.
“Effective systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Food and fluid monitoring
needs fixingFood and fluid charts were incomplete, and weights were not always recorded. Inspectors could not confirm that people had consistently received enough food and drink.
“However, based on food and fluid charts viewed, we could not confirm people's needs had been consistently met.” from the report
Limited activities
needs fixingPeople and relatives reported few daily activities. Activity records were also not detailed enough to show that advertised activities had taken place.
“People and relatives reported limited activities were provided within the home.” from the report
Complaints records
needs fixingRecords often gave only a brief description of what had been done. They did not clearly record how complaints would be prevented from happening again or what had been learned.
“However, we noted the action taken section was often very brief and did not explain what had been done.” from the report
Building and equipment issues
minorOne boiler had ongoing problems and the activity room was cold and unused during the inspection. The provider said repairs were planned.
“However, the activities room remained cold and was not being used at the time of the inspection.” from the report
- 01What checks are now in place to prevent missed or incorrect medicines, and how are medicines given when needed recorded?
- 02How will you make sure care plans, personal care records, food and fluid charts and weight records are complete and up to date?
- 03What daily activities are now available for people, and how do you record whether people have taken part?
- 04What has been done about the boiler and the cold activity room?
- 05How are relatives now involved in care planning and best-interest decisions, and how are complaints and lessons learned recorded?
This was an unannounced inspection covering all five key questions and infection prevention and control; it was the first inspection for this newly registered service, while the previous Good rating was under the former provider. This explanation was written from the published report of 24 February 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.
Every inspection of Pemberton Fold
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2021
Registered with the Care Quality Commission on 12 October 2021.
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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