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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

The last rating for this key question was Requires Improvement. We found a breach of the regulation in relation to good governance.

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

This meant people received a service that was well led.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider’s values were shared with staff during their induction and were regularly reviewed with them ensuring good standards of practice. The provider’s values were also displayed in the entrance hall of the service in a pictorial format making them accessible for all. A folder was also displayed on a stand in the entrance hall, providing people and visitors with information about the service, including the providers complaints policy. The manager and staff displayed a positive caring culture within the service and this enhanced greater trust and understanding between them and the people living at the service.

Information was communicated and shared effectively with staff through daily meetings, supervisions and regular staff meetings. Meetings held showed opportunities for all to comment and provide meaningful input, helping to drive service improvements.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Since our last assessment of the service, there had been changes to the management at the service. There was a new manager in post who had worked for the provider and was familiar with the provider’s policies and procedures. The home manager was in the process of registering to become the registered manager for the service and were 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 home manager was supported by the provider’s head of care and the area manager who offered them continued support and advice. They were also supported by 2 deputy managers and senior staff to help drive service improvements.

Management support was available for staff when they needed it. There was a 24 hour on-call number where staff could contact managers if they needed any advice or support. Staff were positive about how the service was run and about the support they received from the manager. One staff member told us, “The manager is very good, she is always available to support me. I can speak to her anytime.” Another staff member said, “The manager is very supportive, she is helpful and easy to talk to.” Comments from people about the new manager were positive and included, “She has been very helpful”, “She is marvellous, and very helpful”, and “She is very pleasant.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People told us they feel confident speaking up if they had any concerns. A person told us, “I have only ever had minor issues to worry about, and they are dealt with as soon as you make them [staff] aware.”

There were systems to enable staff to speak up. Staff told us they attended regular staff meetings. One staff member said, “The team meetings are helpful. The manager wants to hear our opinions and is very good at communicating with the staff. I can express my views, and I feel that I am listened to. For example, I suggested we have a floating staff member at the service when staff called in sick. The manager listened and put this into action.”

Information about how to raise concerns was clearly displayed within the service in accessible formats.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider supported staff to feel included and treated them with equity, taking account of their individual needs. A staff member told us, “Things are much better now with the new manager. The manager really listens to our ideas and suggestions.”

The service operated an employee of the month programme where staff were rewarded for their hard work. The manager told us 3 staff members had been nominated for the provider’s national staff awards. A staff member told us, “I like working here, there is a family atmosphere, and I feel respected and valued.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Following our last assessment of the service, the provider sent us an action plan which recorded what changes they would be making to improve governance and oversight within the service. Appropriate actions had been taken to address the shortfalls and breaches of regulations, and we saw that these had been embedded within the service to help maintain good quality monitoring.

There were robust systems in place for monitoring and improving the quality of the service. These included audits and checks to monitor and ensure people received safe care and treatment. Managers completed a range of audits, checks and observations which covered areas such as medicines management, safeguarding, accident and incidents, care plans and records, staffing, complaints, health and safety and the home environment. Upon review, we saw that where issues had been ongoing or been identified, action had been taken, and managers monitored the progress of improvements and practice to ensure they were fully embedded.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Leaders built good relationships with external health and social care professionals to make sure people received the right care at the right time.

The manager told us they worked in partnership with others including the GP practice, district nurses, speech and language and occupational therapists and a pharmacy. They worked closely with the local authority’s commissioning team who had been supportive and told us any advice they provided was always helpful.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice and research.

There were systems in place for learning. The manager attended provider forums run by the local authority. They received regular newsletters and meeting minutes following these meetings. They told us they had used some of what they had learned at these forums to make improvements at the service.