Pemberton Fold

Updated 13 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors and 1 Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Pemberton Fold is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pemberton Fold is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A manager was in post at the time of this inspection but later left. The provider appointed a new manager to the role.

Notice of inspection

This inspection was unannounced. Inspection activity started on 27 July 2023 and ended on 25 August 2023. We visited the location’s service on 2 and 8 August 2023.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 9 people about the care they received, and 4 relatives about their experience of the service provided. We spoke to 20 members of staff during the 2 days of inspection. These included the Director of Operations, 3 members of the improvement team, the manager, 6 care staff, 3 team leaders, 1 activity co-ordinator, 2 housekeepers, maintenance staff and 2 cooks.

We reviewed 3 staff files in relation to recruitment. We looked at 4 people’s care plans in detail and other care records on the electronic system. We reviewed records relating to medicines management and a variety of records relating the management and quality monitoring of the service. We spoke with a visiting health professional on site and another professional involved with the home after the inspection. We continued to liaise with management around the secure supply of evidence.

We spoke with the nominated individual, on site on the second day of our inspection. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 13 September 2023

About the service

Pemberton Fold is a residential care home providing personal care for up to 60 people aged 65 and over. At the time of the inspection the service was supporting 41 people, some living with a diagnosis of dementia.

The home has 4 separate units, or households, all with ensuite facilities. Each household operates as a self-contained unit with 15 bedrooms, communal areas such as a lounge, dining area and bathrooms, and a small satellite kitchen. The home also benefits from a hairdresser’s salon, a large activities room and external gardens.

People’s experience of using this service and what we found

People's medicines were not managed safely. We identified issues with staff training and competency checks, gaps in recording and stock balance errors. The monitoring of temperatures of the rooms and fridges where medicines were stored was not consistent.

Not all risks associated with people's care were documented and managed in a way which kept them safe. There were enough staff to keep people safe and meet their needs. There were occasions when staffing levels might be lower, for example during instances of short notice unplanned staff absences, however, people we spoke with told us they felt safe.

Premises checks and all maintenance records were up to date. Required test and safety certificates were in place. Systems were in place to protect people from abuse and people told us they felt safe living at the home. The environment was spacious and dementia-friendly, although some outside garden areas were overgrown and potentially unsafe. A new contract was in place to address this.

Staff training was documented on a matrix, although some elements of refresher training were not up to date for all staff. Staff received relevant training to perform their roles and help meet people's needs. People’s dietary needs were communicated to catering staff on admission into the home. People had mixed views on the food. Three people complained to us that the food wasn’t always hot. As people’s needs changed, referrals were made to relevant professionals for assessment and advice to ensure they could eat and drink safely.

Care plans were now electronic and did not always contain enough detail or reflect people’s care preferences. People and their relatives were involved in care planning, but we were not assured this was reflected on electronic systems.

The team of activity co-ordinators had increased to 3. Activities had improved and the team encouraged people to become involved in both group and individual activities. The home benefited from a large activity room and grounds outside the home. End-of-life care provision was supportive and compassionate.

Since the last inspection there had been limited involvement and oversight from the provider. Audits had not been undertaken in line with company policy, nor had they been effective in identifying and resolving areas for improvement to ensure compliance with the regulations. The provider had not ensured staff were adequately trained and competent in using new electronic systems, and support with this had been delayed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was requires improvement (published 23 February 2023) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of falls. This inspection examined those risks.

You can see what action we have asked the provider to take at the end of this full report.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service on 14 and 15 December 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the Key Questions of Safe, Effective, Responsive and Well-led.

The overall rating for the service has remained requires improvement based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the Safe, Responsive and Well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pemberton Fold on our website at www.cqc.org.uk.