Pemberley House

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.