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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm

The last rating for this key question was Requires Improvement. We found breaches of regulations in relation to need for consent, safe care and treatment and staffing. We took enforcement action and served a warning notice on the provider to become compliant with the regulation in relation to safe care and treatment.

At this assessment we found improvements had been made, the provider was no longer in breach of the regulations, and the rating has now improved to Good.

This meant people using the service were protected from abuse and avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated when required ensuring safety events were appropriately reported and managed. Lessons were learnt to continually identify and embed good practice.

There were robust systems in place for responding to incidents, accidents and complaints and staff we spoke with were knowledgeable about these. Daily staff meetings were held providing effective communication between staff at changes in shifts. These provided staff with information regarding any changes in people’s needs and any service improvements and lessons learnt. Records showed that following events, managers actioned changes where required, which were reviewed and monitored to ensure they were embedded.

The provider worked with people and health and social care partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

Assessments of people’s needs, risks and wishes were completed and continually reviewed to ensure they were reflective of people’s needs. People told us they felt confident their needs would be met by staff and any health-related concerns would be shared with health and social care professionals to promote continuity in care. A relative commented, “They [staff] have been very quick getting a dietician, but we have other people booked for them too.”

Information from visiting health and social care professionals was documented within people’s care records. This ensured up to date information was available to staff when they needed it. Care plans were developed and shared with health and social care professionals when required to ensure individuals’ continued well-being. Staff worked effectively with health and social care professionals to ensure people received appropriate support when meeting their physical and mental health needs. A visiting health care professional told us, “Communication within the staff team is very good. They follow instructions carefully and express concerns in a timely manner.”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

People told us they felt safe with the staff that supported them and staff were available when required. Comments included, “There is usually someone reacting fast to calls or anything that happens, I think that there are enough staff”, “They [staff] are really really helpful, and they talk to me as a human being, of course I feel safe with them”, and “Both of my parents trust them implicitly and so do I.”

Safeguarding policies and procedures were in place and staff were trained to recognise and respond to concerns, potential abuse and harm. Staff told us they were confident any concerns would be managed appropriately. Information relating to safeguarding and how to raise concerns was well displayed throughout the service and in the main entrance hall. Information was accessible and provided people with easy-to-follow information.

There were systems in place to ensure good oversight of all safeguarding concerns and accidents and incidents. The home manager showed us tools used to manage these, and which supported staff to learn when things went wrong. Records showed appropriate actions were taken by staff where required and there were good working relationships in place to minimise the risk of reoccurrence.

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of liberty Safeguard (DoLS) authorisation was applied for through the relevant local authority. All legal applications had been made in accordance with DoLS, this meant people’s rights were fully respected. The home manager had oversight of DoLS applications, authorisations, and conditions and used tools to ensure all documentation was in date.

Staff worked well with people to fully understand and manage identified risks by thinking holistically. Staff provided care that met people’s needs and was safe, supportive and enabled them to do the things that mattered to them. 

People were involved in assessing the risks to their wellbeing and planning measures to reduce the recurrence of identified risks. A person told us, “We [and staff] have frequent chats about them.” Care plans and risk assessments were clear and accessible which supported people and staff to help keep people safe. Throughout our assessment we observed staff working in line with assessments and guidance. For example, when supporting people to mobilise and transfer using equipment. A person told us, “I have to have the hoist to get on and off this chair and it could be nerve-wracking but with them [staff] it isn’t.”

Care plans were developed following assessments to support, manage and review identified risks. Care plans we looked at detailed individual identified risks and the actions required by staff to ensure people’s safety and wellbeing. Some care plans required minor improvements which were brought to the home managers attention who took immediate action to address the minor areas.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design of the premises was safe and met people's needs. People and their relatives told us they liked the home environment and that it was kept clean. Comments included, “Look at the carpets, immaculate”, “Really lovely and clean and no smells”, and “It is beautiful.”

The service was spacious, well-furnished and well decorated. The service provided a dementia-inclusive environment for people living with dementia. The top floor of the service was decorated in dementia-friendly colours. There were sensory boards 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 service with suitable furniture for people to enjoy when they wished.

A member of the home’s maintenance team showed us records from regular audits and safety checks they carried out in people’s rooms and on equipment used throughout the service. These audits covered maintenance, health and safety, infection control and moving and hoisting equipment. We saw servicing certificates for the service’s fire alarm system, portable appliances, gas safety and legionella testing. We also saw checks and audits were carried out on the call bell system, window restrictors, water temperatures and wheelchairs.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People and their relatives told us they felt there were enough staff to meet their needs. Comments included, “I think so, I generally sit out here where there is always someone coming and going”, “Yes, I do think there are enough, and they [staff] answer quickly”, “Yes, they [staff] are working so hard, but they answer bells quickly”, and “Yes, I have parents here and I am very happy with the level of staff as with all aspects of care.” The manager told us they regularly monitored call bell response times and were continually working to improve response times.

The manager showed us a staffing rota and a dependency tool they used to determine staffing levels and told us staffing levels were arranged according to the needs of the people using the service. We observed there were enough staff deployed throughout the service to meet people’s needs. A staff member told us, “We have enough staff, the night staff help people to get ready in the mornings. This makes things easier for the day staff.” Another staff member said, “We have enough staff to meet people’s needs, and we have time to sit and chat with people.”

Robust recruitment procedures were in place. Recruitment records included proof of identification, application forms with employment histories, employment references, health and right to work in the UK checks. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff had the knowledge and skills required to meet people’s needs. The provider’s training matrix showed staff had completed training in areas such as dementia awareness, mental health, autism, diabetes, epilepsy, oral health, nutrition and hydration, fire safety, infection control, medication awareness, equality and diversity, moving and handling, safeguarding adults and children, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). A staff member told us, “I have had a lot of training, and I do refresher training too. The dementia awareness training was very helpful as it made me understand that the condition is a gradual process and what I need to support people with their needs.” We saw a supervision matrix that confirmed staff were receiving regular supervision and appraisals from their line managers.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected from the risk of infection because the premises and equipment were kept clean and hygienic. Staff were observed using personal protective equipment (PPE) appropriately and when required. We saw the service held appropriate stocks of PPE. The service’s infection prevention and control lead showed us cleaning schedules for each floor of the service and told us these were in place to ensure that all parts of the service were kept clean and free from potential infections. Observations throughout our visit demonstrated the environment was clean and odour free.

The provider had an up-to-date infection prevention and control policy in place. The infection prevention and control lead showed us the annual infection prevention and control audit carried out in 2025. No actions were required following the audit. They showed us monthly audits, these indicated that the service had acted on issues when they occurred.

Staff ensured medicines and treatments were safe and met people’s needs, capacities and preferences. People told us they received their medicines when required. Comments included, “Always at the same times”, “No problems at all”, and “Yes, they [staff] make sure they are taken.”

Medication management was reviewed in line with regulatory requirements and best practice guidelines. This included checks on how medicines are stored, administered, recorded, and reviewed, as well as how staff are trained and supported in this area.

Medicines were stored securely and room and fridge temperatures for medicine storage were monitored and recorded daily, with records available for review. Medicines were administered by trained staff who had completed up-to-date medication competency assessments. Staff followed the provider’s medication policy and received annual refresher training. Medication rounds were unhurried and staff were observed checking MAR (Medication Administration Record) carefully before administering medicines. MARs were completed accurately, with clear signatures and codes for non-administration where appropriate. A small number of gaps were identified where the reason for omission was not recorded. We discussed this with the manager who took immediate actions to address the issue. PRN (as required) medication protocols were in place.

Regular audits of medication practices were carried out by the management team. Where issues were identified, action plans were put in place and followed up to completion. A pharmacy audit conducted in January 2026 identified that covert medication guidance required updating. The manager had implemented steps to address this, including regular internal audits and a system for documenting and sharing lessons learned from any medication errors.