CQC report explained · a nursing home
What the CQC found at Pembroke House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2021
Pembroke House was rated Good; inspectors found caring, safe care, with some records and call-bell problems.
This was an unannounced focused inspection on 09 August 2021. Inspectors looked at Safe and Well-led because of information suggesting possible risks. They spoke with people, relatives, staff and professionals, and reviewed care, recruitment, medicines, safety and management records.
The home was rated Good overall. Safe was Good and Well-led was Good. Inspectors found that people were protected from abuse, risks were assessed, medicines were managed safely and infection-control arrangements were suitable.
People and relatives described staff as caring and respectful. Staff were seen as approachable and supportive, and the management team used meetings, audits and feedback to make improvements.
There were some shortfalls. Repositioning records were not always completed, and the call-bell system was not working during the inspection. The call-bell system was restored shortly afterwards, and the manager said repositioning records would be monitored.
Caring relationships
People and relatives said staff were caring, respectful and supportive. Everyone spoken to said they would recommend the home.
“People and their relatives told us that they experienced a service where staff were caring and respectful.” from the report
Medicines
Medicines were stored securely, given as prescribed and checked through audits. Staff administering medicines were trained and assessed.
“Medicines continued to be stored, administered and disposed of safely.” from the report
Risk management
The home had detailed plans for risks such as falls, choking, wounds, catheters and feeding tubes. Staff had guidance on how to support people safely.
“There were detailed plans to minimise risks associated with people's health and nursing needs.” from the report
Open management
Staff said they felt more supported and listened to under the new management team. The home used meetings, audits and feedback to identify improvements.
“The culture of the service was open and honest.” from the report
Repositioning records
needs fixingAlthough people's skin was kept healthy, records showing when people had been repositioned were not always completed. The manager said these records would be monitored after the inspection.
“Although people's skin was kept healthy, by them being moved regularly, repositioning records were not always completed.” from the report
Call-bell system
needs fixingThe call-bell system was not operating during the inspection. Temporary bells were being used, but relatives raised concerns about how well staff could identify which person needed help. The system was working again shortly afterwards.
“At the time of the inspection the call bell system was not operating.” from the report
- 01How do you now check that repositioning records are completed for people at risk of skin deterioration?
- 02Has the call-bell system remained reliable since it was restored after the inspection?
- 03What temporary arrangements would be used if the call-bell system failed again?
- 04How do you use audits and incident reviews to check that identified improvements have been completed?
- 05What were the ratings for Effective, Caring and Responsive at the last comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 25 September 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2018
Rated Good; inspectors found safe, kind and responsive care, with a recent staffing shortfall on one floor addressed during the visit.
Inspectors visited without warning on 13 and 14 June 2018. They spoke with people living there, relatives, visitors and staff. They observed care and checked care records, medicines, staff records, training, complaints and safety documents.
The home provided residential and nursing care for up to 55 older people. There were 49 people living there during the inspection. All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led.
Inspectors found improvements since the previous inspection in 2016. Medicines were now managed safely, and care plans and risk assessments had improved. People described kind care, good activities, suitable food and support with health needs.
People and staff reported that afternoon staffing on the ground floor had recently sometimes been too low, causing delays when people called for help. The manager added another staff member to that shift during the inspection.
Safer medicines
A new electronic medicines system alerted staff when medicines were due and if one had not been given. Records and audits showed no missed medicines since it was introduced.
“Since the system had been introduced there had been no gaps in recording of people's medicine records and medicine audits showed there had been no missed medicines.” from the report
Kind and respectful care
People were treated with patience and respect. Inspectors saw staff explaining what they were doing, asking permission and supporting people to do things for themselves.
“Staff provided caring and considerate support and respected people's privacy and dignity.” from the report
Good activities
Activities were planned well in advance and included events, outings, entertainment and individual support. Volunteers helped people who stayed in their rooms as well as those attending group activities.
“An activities coordinator and an assistant, planned activities each week and many months ahead.” from the report
Clear oversight
The home used regular checks of care plans, risks, staff records, training and medicines. Meetings and surveys allowed people, relatives and staff to give feedback.
“An auditing programme was in place, which monitored the quality and safety of the service provided.” from the report
Afternoon staffing on the ground floor
needs fixingPeople and staff said that staffing on the ground floor afternoon shift had recently not always met people's needs. One person described waiting for help, although the manager added another staff member to the shift during the inspection.
“I need two people to help me and there have been times when I ring my bell and I wait and wait” from the report
- 01Has the additional afternoon staff member on the ground floor remained in place, and how quickly are call bells answered now?
- 02How will you make sure there are enough staff when several people need help at the same time?
- 03How will my relative's medicines be recorded and checked using the new electronic system?
- 04How will my relative and our family be involved in creating and reviewing their care plan?
- 05Which activities and outings would be suitable for my relative, including if they need nursing care or prefer to stay in their room?
This was an unannounced inspection of the overall service and all five CQC questions, including accommodation, nursing care and personal care. This explanation was written from the published report of 9 August 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Pembroke House
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- September 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Goodstayed GoodSafe: GoodWell-led: Good
- October 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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