Pemberley House

Updated 30 December 2022

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

This inspection was undertaken by three inspectors. The site visit was undertaken with a Hampshire Fire Officer as an inter-agency learning opportunity. An Expert by Experience supported the inspection remotely. 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

Pemberley House 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. Pemberley House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the 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 visited the site on 25 and 31 August 2022. We reviewed the home environment, made observations of mealtimes, medicines administration and staff interactions with people.

We spoke with the registered manager, operations manager, regional assurance manager and nine members of staff, including the deputy manager, maintenance staff, chef and care staff. We spoke with seven people using the service, and nine people’s relatives.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed six people’s care plans, a number of medicines records and other care records. We reviewed policies and procedures, training records, audits and other records in relation to the running of the service.

Updated 30 December 2022

About the service

Pemberley House is a nursing and residential home supporting up to 72 people who may be living with physical disabilities or dementia. The home is split into five units, each of which has ensuite bedrooms, living areas, a kitchenette and an outdoor space. At the time of our inspection there were 56 people using the service.

There were two companies registered as providers for Pemberley House: Willowbrook Healthcare Limited and WT UK OPCO 1 Limited. Both legal entities are equally responsible for how the service is run and for the quality and safety of the care provided.

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

Some aspects of health and safety in the home were not managed safely. Medicines were not always managed safely, and people did not always receive their medicines as prescribed. Recruitment procedures did not reflect the requirements of the regulations, and not all staff had appropriate pre-employment checks.

Quality assurance measures in place were not always robust, some issues identified on inspection were not appropriately identified and prioritised by the provider. Some records were not up to date or consistent. Staff described a blame culture between managers and other staff.

The home décor was not always well maintained and was not in line with dementia friendly guidance. Some staff training was not up to date in line with the provider’s policy, particularly aspects of clinical care for people.

People’s care plans were not always person-centred. Activities in the home were limited, particularly for people who were less able to participate in group activities. Staff and relatives fed back that there was not always time for staff to dedicate one-to-one time with people for reminiscence or activities. The home was in the process of recruiting another activities co-ordinator.

Some aspects of care were not in line with best practice, the home had not yet rolled out up to date guidance on standardised food textures. We identified people, or their legal representatives were not always asked for proper informed consent to share pictures and videos of them.

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.

People and their relatives said that staff were caring and kind. We observed staff were patient and compassionate towards people. Staff knew people well and managed their anxiety well. The home was clean and tidy, and risks to people’s individual health and safety were appropriately assessed.

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

Rating at last inspection

This service is registered under two legal entities. The service was inspected when registered with Willowbrook Healthcare Limited. The last rating for the service was good.

Since that inspection, the service registered with a second legal entity, WT UK OPCO 1 Limited, on 6 September 2019. This is the first inspection since this registration.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, fit and proper persons employed and good governance at this inspection.

We made recommendations for the provider to implement best practice in relation to food textures, in reflecting dementia friendly décor; and reviewing their social media policy in line with the mental capacity act.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.