Pemberley Manor Care and Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found there were no robust, clear and effective governance arrangements in place to oversee the service delivery and ensure peoples safety. The providers audits failed to identify the issues we found with medicines management, assessments of people’s care and support needs, care plans and risk assessments and mental capacity assessments. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Pemberley Manor Care and Nursing Home registered with the CQC on 3 April 2024. The manager told us nursing care would no longer be provided from 16 December 2024. The had consulted with people using the service, relatives, staff and the local authority in the transformation process. At the time of our visit the service was providing nursing care to 9 people and 60 older people some of whom were living with dementia.

There was an organisational structure in place and staff understood their roles, responsibilities and contributions to the service. The deputy manager told us, “We are getting there, we have more processes now, my role did not exist before but now checks are being done, the checks and audits now happening and up to date.”

We saw an action plan for transitioning the home from a nursing care provider to a residential care home/provider. The action plan included consultation dates with people using the service, relatives, staff and local authority commissioners. It also included support for people using the service and their relatives throughout the transition, the recruitment of additional senior staff and training staff on the administration of medicines.

We saw letters that were sent to the relatives of people in receipt of nursing care at the home about the planned changes. We saw the minutes from a meeting held with residents and relatives informing them of the planned changes. A representative from the local authority’s placement team attended this meeting to support and sign post relatives who had questions about the process. Following the inspection the provider told us they no longer provided nursing care. An application has been received by CQC to remove nursing care from the home’s registration.

The home did not have a registered manager in post. The current manager had been at the home since June 2024. They had applied to the Care Quality Commission to become the registered manager for the home. The manager told us they were getting to know the company and the home. The manager was supported at the home by a deputy manager. They were supported on a weekly basis by the area manager. The provider also visited the home monthly and offered further support and checked if there was anything they needed.

The manager attended meetings with the providers other home managers to learn and share good practice. At a recent manager meeting they discussed issues such as CQC inspections and lessons learned.

A staff member told us, “I get support from the manager, morale is good, and the home is definitely getting getter.” Another staff member commented, “The manager is trying his best to make things better at the home. His attitude is good.” A third staff member said, “The manager is doing his level best. The immediate enthusiasm is there but sometimes we ask for the same things in relation to staff numbers.”

The manager was knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about and records showed the service had submitted notifications to CQC where needed.

The providers nominated individual carried out monthly quality checks at the home and was supporting the manager in this process.

Throughout this assessment staff raised concerns with us about the current staffing levels at the home. A staff member told us, “The manager is new, he started earlier this year we have spoken to him about our concerns, but he too is finding his feet and says everything will settle.”

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.

The manager told us a satisfaction survey had recently been sent out to people using the service, relatives, professionals and staff. They were waiting for responses prior to assessing the feedback and drawing up an action plan.

Staff told us the manager was approachable and listened to them. One staff member commented, “The manager is always here he showed me around when I started working here. He is good and I can approach him if I need anything.”

The manager told us a satisfaction survey had recently been sent out to people using the service, relatives, professionals and staff. They were waiting for responses prior to assessing the feedback and drawing up an action plan.

The manager and area manager told us about the changes and improvements planned for the home. These included areas such transitioning from nursing care to residential care provision, reviewing and updating peoples care plans, recruiting and training senior staff and activities coordinators, and improving activities at the home.

The manager and regional manager told us they had introduced a ‘Resident of the day’ programme. This ensure 1 person’s care plan from each floor would be reviewed every month to ensure all care plans and records were reflective of people’s needs and risks.

A member of the maintenance team confirmed that regular checks were being carried out on the electrical, fire alarm, gas safety, legionella, call bell system, hoists, wheelchairs, and pressure relieving mattresses.

There were no robust, clear and effective governance arrangements in place to oversee the service delivery and ensure peoples safety. The providers audits failed to identify the issues we found with medicines management, assessments of people’s care and support needs, care plans and risk assessments and mental capacity assessments. Checks on airflow mattresses were not always set correctly.

The homes improvement plan updated on 2 October 2024 included issues relating to the management of medicines. However, we found medicines were being poorly managed the audit had not identified the concerns we found during our assessment. The improvement plan also indicated that, 66 peoples care plans were audited in the month of September 2024.

We saw a report from a visit carried out by the provider 3 September 2024. This identified shortfalls and actions for improvement. The report identified some of the areas we found during our assessment in relation to care planning, nutrition and medicines however not all the actions had been addressed. The report did not include a time scale for the actions for improvement to be completed.

Despite these audits we found that people’s care plans, assessments and risk assessments were not always completed nor reflective of their needs and risks and were not always person centred. Mental capacity assessments were not always completed in line with the codes of practice or had not been completed at all where required. The providers quality assurance systems that were in place failed to identify the issues we found during our assessment of the service.

We saw the providers risk register for September 2024. This was used to monitor areas such as care plans, falls, safeguarding and complaints. The care plan audit (referred to in the homes improvement plan above) had identified deficits in peoples cares plans. We saw positive action was taken for example in relation to a person that had 7 falls in September, the person had no falls in October.

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

The manager told us they had linked up with the local authority and planned to attend a provider forum in November 2024. The manager told us the new activities lead would be attending an engagement well-being forum run by the local authority.

A visiting health care professional told us there were some difficulties with communication between the home and the GP practice as there was no system in place whereby email could be used. There had also been issues concerning their phone lines. Both issues have had a negative impact on patient care from missed specialist appointment, late medication requests being actioned and duty doctor not being able to contact the home.

Records showed that the manager and staff worked in partnership with other agencies, including the local authority and health and social care professionals. The manager told us the commissioning team had been extremely supportive.

The manager told us the local authority commissioning team had visited the home and had offered advice and support. The manager said the commissioning team had been extremely supportive.

The manager told us a satisfaction survey had recently been sent out to people using the service, relatives, professionals and staff. They were waiting for responses prior to assessing the feedback and drawing up an action plan.

The manager told us they were following advice from the care home quality liaison nurse they planned to use restore 2 and a universal care plan. Restore 2 is designed to support homes and health professionals to recognise when a resident may be deteriorating or at risk of physical deterioration and act appropriately according to the resident's care plan to protect and manage the resident. There were plans for senior staff to attend restore 2 training with the local authority on the 8 November and in house on 12 November 2024.