Pemberley Manor Care and Nursing Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We found that assessments of peoples need were not always completed, detailed or reflective of people’s needs. People's diet, nutrition and cultural needs were not always assessed and met. This was a further breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were involved in planning for their care needs. One person said, “The staff went through everything with me.” Another person told us, “Me and my daughter did my care plan with the care manager.”

The manager and regional manager told us that assessments of people’s needs were conducted prior to admission to the service. They told us they completed a care plan audit on a weekly basis where 5 care plans are reviewed and audited with any changes and updates made as required. They told us about the ‘Resident of the day’ programme which was being implemented in the service. This meant 1 care plan from each floor within the service is reviewed every month by a member of staff.

The manager told us that the electronic care planning system was implemented in May 2024 and the transfer of all care planning data from the previous provider was completed in June 2024. The manager commented that staff had recently received further training on the electronic care planning system to help them complete required tasks.

Planning for people’s care and treatment was not always effective. People needs and risks were assessed for areas such as personal care, communication, memory and understanding, mobility and risk of falls, nutrition and hydration, skin, medication, activity and socialising. However, care plans and assessments were not always completed, detailed or reflective of people’s needs.

For a person who had been living at the service for more than a year we saw that they had no information documented about them in their biography, no personal information such as their religion/ethnicity/nationality had been gathered or documented, there was no pre admission assessment completed, no allergies recorded, no information recorded in their personal preferences and no end of life information recorded. This placed people at risk of receiving poor or inappropriate care and support.

Comments from people about food provided at the home was mixed. One person told us since the new provider took over there had been a reduction in the quality of the food. Another person said, “The food has changed and not for the better, it is not as good, the choice not so good. There are not enough vegetables”. Other comments included, “They offer me lots of different foods. The food is always what I want,”, “The food is pretty good, plenty of variety, definitely have enough fruit and vegetables, mid-morning I get a plate of fruit, all sorts of fruit, that’s my treat every day.” And “I love the food here. The chef is amazing.”

We observed people having lunch in the dining areas and in their rooms. Staff were seated with people when providing support to give good eye contact, talking to the person and providing words of encouragement to promote the person’s well-being. People were given choice on what they wanted to eat. People were supported to eat and drink by staff in an unhurried and caring manner.

A member of the kitchen staff team was knowledgeable of people’s dietary needs. They told us about people’s food preferences and cultural requirements. For example, people’s vegetarian and pescetarian and halal meal preferences. They showed us information in the kitchen which detailed people’s individual dietary needs for example some had allergies, and some had modified textured diets.

People's diet, nutrition and cultural needs were not always assessed and met. Care plans documented people’s nutritional needs which detailed their levels of diet and appetite, allergies, food intolerances, cultural preferences, special requests and dining preferences including drinking utensils and cutlery. However, care plans did not always document people’s nutrition and hydration intake where it was identified as a need or risk.

For people who were identified as being at risk of constipation we saw that there was no fluid targets set to minimise the risk of constipation in line with best practice. For one person it stated that they should have up to 2 litres of fluid a day, but their intake recorded only 960mls was taken. Other fluid records we checked showed inconsistencies in recording with many not detailing what fluids were given. There was no system in place to check that people at risk were receiving an appropriate amount of fluid. Care plans and risk assessment did not specify at what point staff should take action to prevent harm.

People had access to health care professionals when they needed them. One person told us, “The district nurse comes every 4th day to dress my legs.” Another person told us they had seen an optician and a chiropodist.”

The manager told us people had access to healthcare services. These services included visiting chiropodists, dentists, and opticians. A GP visited the home on a weekly basis to support people with their medical needs.

A health care professional told us, they had worked with senior carers that had always given clear feedback, spent time discussing cases with them and provided them with any information they had requested. These staff displayed good knowledge about the person living in the care home and they had developed a positive relationship with the person's family member who visited almost daily. Whenever they suggested referring people onto other professions, e.g., Speech and Language Therapy they were actioned by staff. Staff are always accessible during their visits and over the phone.

Another visiting health care professional told us there is not always an allocated staff member, to support them, who knew people well enough or the concerns they had to address. They did not feel that staff triaged those in most need for them to see.

Care records showed people were supported by health care professionals including a tissue viability nurse, speech and language therapist, GP, dietitian and a falls team. Community nurses were also attending the home to manage nursing needs of residents deemed as ‘residential’.

People had access to health care professionals when they needed them.

The manager told us people had access to healthcare services. These services included visiting chiropodists, dentists, and opticians. A GP visited the home on a weekly basis to support people with their medical needs.

Care records showed people were supported by health care professionals including a tissue viability nurse, speech and language therapist, GP, dietitian and a falls team. Community nurses were also attending the home to manage nursing needs of residents deemed as ‘residential’.

The provider supported people with their physical support needs. People had access to equipment when they needed it.

Suitable equipment to prevent falls or to mitigate the risk of injury were used appropriately following assessment of people’s needs. We saw the homes risk register for falls. This showed that person had 7 falls in September. The manager told us the person was referred to the fall’s clinic, the GP reviewed the persons medicines, and staffing levels was increased. The person had no falls in October.

Care records showed people were supported by health care professionals including a tissue viability nurse, speech and language therapist, GP, dietitian and a falls team. Community nurses were also attending the home to manage nursing needs of residents deemed as ‘residential’.

People told us they were involved in planning for their care and support needs.

The manager and regional manager told us about the ‘Resident of the day’ programme which was being implemented at the service. This meant 1 care plan from each floor within the service is reviewed every month by a member of staff to ensure all care plans and records are reflective of people’s needs and risks.

Staff were aware of the importance of seeking consent from the people they supported and had received training for The Mental Capacity Act 2005 (MCA). However, people’s consent was not always sought and assessed when planning for their care and support needs.