Pemberley Manor Care and Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found that risks to people were not always identified, assessed, documented, and reviewed to ensure people’s safety and well-being. People's medicines were also not managed safely. These shortfalls were a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. We found there were always not enough staff on duty. This was a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. We found that mental capacity assessments were not always completed in line with the codes of practice. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People did not make any comments about learning culture.

There were systems in place to oversee learning from safeguarding and accidents and incidents. The manager and regional manager kept and managed a tracking tool to monitor all safeguarding concerns raised, and any outcomes including lessons learnt. The regional manager told us meetings were held with staff where they shared any lessons learnt.

The regional manager told us that clinical risk governance audits were completed where all safeguarding concerns were logged and monitored. They told us there was also a provider risk register in place which was monitored monthly to ensure good oversight. Records we looked at confirmed this.

A staff member told us, “I started working here 4 months ago, I have had one supervision meeting in that time, but it is ok staff are very helpful.” Another staff member said, “Supervision is not very often, we do not have time.”

The manager was the safeguarding lead for the service, and they were knowledgeable about their responsibilities and their Duty of Candor. The regional manager also had oversight of learning lessons from safeguarding concerns raised, accidents and incidents and any adverse events. Records showed that lessons learnt were shared with staff and any actions were implemented where required.

People told us they had access to health care professionals when they needed them. A person told us, “GPs come, I need a dentist, saw the GP last week and they said she would try and find me one.” Another person said, “I have seen an optician privately and the chiropodist has been to see me.”

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

The manager told us they were always open and transparent with family members and professionals and took responsibility when things went wrong.

A staff member told us, “Myself and other care assistants across each floor do not have much contact with visiting GPs. We just show the GP where the residents are. Communication is good between senior care assistants and care assistants; it must be as we are short of staff most of the time.”

A visiting health care professional told us that signs of deterioration in residents had not been brought to them in a timely manner. Instead, it was left to the GP round when it should have been addressed sooner. Things would be written in the GP’s book by staff, which was unclear, lacked detail and had no accompanying observations. A lot of time was spent trying to work out what the issue was.

Another health care professional told us, staff displayed good knowledge about a person living in the care home and have developed a positive relationship with the person's family member who visits almost daily.

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 when required. Community nurses were also visiting the service to manage people’s nursing needs.

One person told us, “Staff mostly are nice except for the night staff they are the worst and treat you like you are a bit of dirt – it is the way that they push and shove you around, no point in complaining, waste of time.” We reported this comment to the home manager to address. A relative commented, “I don’t feel my loved one is safe when I leave.”

The manager told us they were aware of their responsibility to report allegations of abuse and how to refer to the local authority safeguarding team and CQC where required.

Staff told us they had received training on safeguarding adults from abuse. A staff member told us they would report any abuse or poor care practice to the nurse in charge and the home manager. They were confident the manager would make a referral to the local authority safeguarding team and CQC if they needed to.

We saw staff spending time with people providing support and showing care and concern for their well-being.

People were supported to stay safe and were safeguarded from abuse and avoidable harm.

There were systems in place to oversee learning from safeguarding, accidents and incidents, falls and adverse events. The manager and regional manager oversaw a tracking tool which monitored safeguarding concerns raised, and any outcomes including lessons learnt. We saw that staff meetings were held where managers shared any lessons learnt with staff implementing required actions where appropriate.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

We checked whether the service was working within the principles of the MCA, whether any restrictions on people’s liberty had been authorised and whether any conditions on such authorisations were being met. People were consulted and supported by staff to make choices and decisions for themselves. Staff were aware of seeking consent from the people they supported and had received MCA training.

MCA’s were not always completed in line with the codes of practice or had not been completed at all where required. For example, a person living with dementia did not have an MCA or best interests completed despite documentation recording they could display some distressed behaviours.

One person told us, “I do feel my needs are met.” Another person said, “The staff do the bare minimum.”

Staff told us the lack of staff numbers was placing people at risk of not receiving care in a timely manner and in line with their care plans and risk assessments. One staff member told us on some occasions they had to administer medicines to people on two parts of the home due to lack of staff assessed as competent to administer medicines. They said, “Quite frankly, this is risky.”

We saw staff spent time with people providing support and concern for their well-being.

Risks to people were not always identified, assessed, documented, and reviewed to ensure people’s safety and well-being. Where risk assessments were completed and documented they were not always detailed recording how the risks should be mitigated, they did not include the actions required by staff to ensure people were kept safe. For example, some people did not have risks relating to their catheter care, mobility, sensory impairments, or other healthcare conditions documented within their plans of care.

For a person who was identified as being resistant to care and demonstrating distressed behaviour, their risk assessment failed to detail how this behaviour was triggered and how risks could be mitigated. Their care plan documented that a recording tool was to be used to monitor their behaviour, however records showed this this had not been completed.

Where people exhibited behaviours that could be distressing to themselves and others, records failed to demonstrate that PRN medication (when required) must only be used when required. De-escalation techniques were not routinely used or considered prior to administering PRN medication.

For people at risk of pressure sores we saw that airflow mattresses were not always set correctly to mitigate the risks. Not all staff understood how the settings worked on each machine. A staff member told us these settings were done by maintenance. A senior staff member told us they did not understand the number of lights on the machine and what this meant. Staff sometimes recorded they had checked the mattresses pressures when attending to people and that it was on the correct setting, however, this appeared that staff were just checking that the mattress were working and not that the settings were correct. We saw that a weekly audit was carried out to ensure that people had the correct setting for their mattresses, but these were incorrect and could pose a detrimental effect on people’s skin integrity.

Comments from people using the service included, “It’s like there living in a 5-star hotel,.”, “I believe it is presented nicely, but I have major concerns around the care received.” And “The maintenance man is excellent; he repaired my chair.”

A member of the home’s maintenance team showed us a maintenance log and told us they kept on top of all the maintenance issues that were reported to them by residents and staff. They also showed us records from regular audits and safety checks they carried out people’s rooms and on equipment used throughout the home.

People's bedrooms were personalised to reflect their own interests and preferences. Some people had their own personal fridge for storing snacks and drinks, dementia aids including calendars and clocks, telephones, photographs, and books were evident.

The service provided a dementia-inclusive environment for people living with dementia. The top floor of the service was decorated in dementia friendly colours and had sensory boards on the wall along the corridors with activities for people to do when walking with a purpose. People had memory boxes located outside their doors to help aid orientation.

There were sufficient communal areas to aid people’s comfort and for them to enjoy a positive dining experience. There were also break out areas for people to sit on their own and or with others, such as family members or friends.

There was a secure garden at the back of the home with suitable furniture that people could enjoy in warm weather.

Regular audits and checks were in place that covered maintenance, health and safety, infection control and moving and hoisting equipment. We saw servicing certificates for the homes fire alarm system, portable appliances, gas safety and legionella testing. We also saw checks and audits were carried out on the call bell system, water temperatures, fire drills and the fire alarm system.

One person told us, “I think we need more carers, last night we had just 2-night carers and they did all of us – 15 – it was frightening for us, they were working so hard and said we are going to come to you, but it was quite late. Usually there are 3 of them.” Another person said, “I did not have a shower for a week as there were only 3 staff on, I can’t ask them to do that and put more pressure on them, I ask first thing in the morning how many are on – should be 5, sometimes 4 and sometimes 3. Today there are 5 because you are here.” A third person commented, “One of the night staff comes in regularly and turns off the buzzer, I give her 10 minutes and then press again, she says that she is with someone else and does this regularly.” We reported this comment to the home manager to address. Following the assessment the manager told us they had carried out unannounced night checks and were investigating this issue with residents and staff.

Other comments from people included, “There is not enough staff here to support all of us.”, “Sometimes I wait up to an hour to get changed in the morning.”, “There is not enough staff, but they do try their best”, “There is never enough staff, but they do what they can.” And “There is not enough staff to cover the people, I press and press the buzzer, they are short staffed, but they work so hard.”

A relative told us, “They are short staffed. There have been times where I have had to do personal care.”

The manager showed us a staffing rota and a dependency tool and told us staffing levels were arranged according to the needs of the people using the service.

Staff told us there were occasions when staffing levels were not always attained due to staff sickness and annual leave. Although efforts were made to utilise existing staff to plug any staffing shortfall, this was not always possible.

One staff member told us, “We have a lot to do to support people on this floor. It is a struggle when we have a senior and 4 care staff. But sometimes we only have 3 care staff which is not enough to meet people’s needs.” Another staff member said, “We are always short staffed, because of this people get “neglected”. There are long waits for people when they press their call bells, there is not enough staff to help everyone with toileting needs.”

A staff member told us about their training, “My induction was very good. I also shadowed experienced staff; this was helpful as I got a good understanding on how to support people. My manager and senior care assistant on my floor are always around to help me if I need anything.” Another staff member commented, “My training and induction with the old provider was very good, it helped me learn my job. The dementia was useful, it gave me a good understanding of what people go through.”

A third staff member commented, “Supervision is not very often. We do not have time. Since the new provider took over everyone is rushing around from one thing to another.

We observed that the staffing levels during our visits to the home reflected the numbers of staff on the staffing rota. Staff appeared to meeting peoples care and support needs.

The providers recruitment process required improvement. For example, we found that gaps in staff’s employment and the reason for them leaving their previous employment had been explored. Where the provider had not received employment references a risk assessment had been completed stating the member of staff would be ‘shadowed’ and receive full induction training. We found no evidence to support this had happened for 4 recently recruited staff. These staffs’ recruitment records did not include a health declaration.

Appropriate checks were carried out relating to Disclosure and Barring Service (DBS) checks and where appropriate, right to work in the UK information. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helped the provider make safer recruitment decisions.

We could not be assured that newly appointed staff had received a suitable induction that prepared them for their role. A member of staff responsible for recruitment told us that newly appointed staff were provided with an ‘in-house induction and training programme document and the providers induction care staff’ document to complete when they commenced in post. However, we found no evidence to support either document had been commenced for any of the files we viewed.

People told us the home was always clean. One person said, “It is ok here, it is kept clean.”

The homes infection prevention and control lead told us they carried out regular monthly infection prevention and control audits. They carried out hand washing and personal protective equipment (PPE) donning and doffing checks with staff to make sure staff were completing these tasks correctly. They showed us locked cupboards on all floors of the home which held appropriate stocks of PPE.

People were protected from the risk of infection because the premises and equipment were kept clean and hygienic. Observations throughout the assessment demonstrated the environment was clean and odour free.

Staff were observed using PPE appropriately and when required. However, consideration should be made prior to people commencing their meals, for staff to offer them an antiseptic gel or wipes to clean their hands.

The provider had an up-to-date infection prevention and control policy in place. The homes infection prevention and control lead told us there was a cleaning schedule in place to ensure that all parts of the home were kept clean and free from potential infections.

Infection prevention and control audits were carried out. The last annual infection prevention and control included an action plan. The homes infection prevention and control lead told us all service acted on the recommendations from the audit which included changing the flooring in a person using the services bedroom.

People were not always receiving their medicines safely or as prescribed. Records showed some people had gone without their medicines. Where there had been a change to a prescription there was no record of the medicine administration chart being updated. This put people at risk of deteriorating health.

People’s choices and preferences about how they wanted to take their medicines were not always taken into consideration. People’s care plans did not always contain enough information about their specific health condition or how these should be managed, this put people at risk of harm. Protocols for when required medicines [PRN] were either not in place or were not reflective of people’s needs. This meant staff did not have access to the correct information to support people with the health needs.

One person told us, “Yesterday my jug went in the morning, and I had to ask several times for it back and eventually got it at 6.30 – I do self-medication 4 times a day. I had to shout out for water as I am supposed to take tablets at certain times.”

Staff said there were not enough medicines trained staff to cover medicines administration which meant staff were not getting time to complete medicines management tasks. Staff had completed training and competency assessments. However, we were not assured all staff were competent with medicines optimisation. The service worked with other health care providers such as the local hospice and dietitians to provide care to people.

Medicines were being poorly managed. People were at risk of not receiving their medicines as prescribed by health care professionals. There were systems and processes in place to manage medicines, however, staff were not always following these. Medicines administration records [MAR] were not being kept up to date. Stopped medicines were still being supplied each month and available for administration. Medicines that were expired had not been identified and staff were over ordering medicines and not disposing of medicines no longer required. Controlled drugs were not being disposed of or stored in line with national guidance.

Staff were not following best practice when administering medicines for example they were signing the MAR chart before the medicines had been administered and not completing records for application and rotation of pain relief patches. Emergency equipment bags had not recently been checked. Some equipment was not working due to flat batteries which put people at risk.

Staff were completing regular audits; however, these had not identified the concerns we found during the assessment. After the first day of the assessment the provider sent us an update detailing what actions they were taking to address the concerns raised.