CQC report explained · a residential care home
What the CQC found at Pembroke Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home was preventing infections, using PPE safely, arranging testing and managing visiting, admissions and possible outbreaks. The provider also said it had measures to reduce the risks from COVID-19-related staffing pressures.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, July 2022
Inspected but not rated; inspectors found good infection control, safe visiting arrangements and measures to manage COVID-19 risks.
This was an announced, targeted inspection on 16 June 2022. It focused on infection prevention and control, visiting arrangements and whether COVID-19-related staffing pressures were affecting care.
Inspectors found that the home had identified and managed COVID-19 risks. Staff used personal protective equipment, people and staff had regular testing, and the home had systems to monitor government guidance and its own policies.
People were supported to leave the home and see relatives. Relatives could visit in communal areas and the garden. Inspectors were assured about the home's arrangements for visitors, admissions, hygiene, testing and managing possible outbreaks.
The home was inspected but not rated. This report does not give a new overall rating or a full rating for all five areas of care.
COVID-19 risk management
The manager had identified and reduced COVID-19 risks to people, staff and visitors. The home also checked that guidance and its own policies were being followed.
“The registered manager had identified, assessed and mitigated all COVID-19 related risks to people, staff and visitors.” from the report
Protective equipment and testing
Staff had suitable protective equipment and extra training on how to use it. People and staff received regular COVID-19 testing.
“Staff wore appropriate PPE and had access to this throughout the home.” from the report
Visiting and community access
People were supported to visit relatives and use the local community. Relatives could visit in communal areas and the garden.
“People were encouraged and supported to leave the service to visit relatives or access the local community.” from the report
Infection control arrangements
Inspectors were assured about the home's hygiene, layout, admissions, visitor arrangements and plans to prevent or manage outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you managing any COVID-19-related staffing pressures now, and could these affect people's care?
- 02Are people still supported to leave the home and visit relatives or use the local community?
- 03What testing and visitor arrangements are currently in place for relatives and professional visitors?
- 04How do you check that staff are using PPE correctly and following infection prevention guidance?
- 05When was the infection prevention and control policy last reviewed?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 12 July 2022 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, October 2019
Rated Good; inspectors found safe, kind and personalised care, with a falls procedure needing review.
This was an unannounced inspection on 2 and 13 September 2019. One inspector spoke with six people living at the home and six staff members. Records about care, medicines, recruitment and management were also checked.
Inspectors found the home safe, effective, caring, responsive and well-led. People said they felt safe and were treated with kindness. There were enough staff, medicines were managed safely, and people had access to food, activities and healthcare.
The home supported people's independence and choices. Staff involved people in decisions, respected their privacy and dignity, and developed care around their wishes and goals. The overall rating was Good, and all five areas were rated Good.
The previous rating was also Good, published in September 2018. The provider had changed since that rating, and the previous rating was used to help plan this inspection.
Enough staff
Inspectors found there were enough staff to meet people's needs. Staff also worked flexibly when people's needs changed.
“There were enough staff to meet people's needs. Staff worked flexibly to meet the needs of people.” from the report
Kind and respectful care
People were treated with kindness and their equality, privacy and dignity were respected. The home had an open and inclusive atmosphere.
“People were treated with kindness. Their equality and diversity were respected.” from the report
Independence and choice
People were supported to make choices, take safe risks and do everyday tasks for themselves, including cooking, making drinks and doing laundry.
“Staff supported people to take risks in a safe way. This maximised their independence, choice and control.” from the report
Personalised support
Care was based on people's wishes, preferences and goals. Staff also helped people continue hobbies, pursue work and take part in the local community.
“People's care was developed around their wishes, preferences and goals.” from the report
Active quality monitoring
The manager and staff used audits, checks, reviews, surveys and meetings to monitor the service and act on issues.
“A range of audits and checks were carried out to monitor the quality and safety of the service.” from the report
Falls procedure to be reviewed
needs fixingInspectors discussed reviewing the falls procedure so it followed best practice after a fall. This was a shortfall to follow up, although the overall Safe rating remained Good.
“We spoke with the registered manager about reviewing the falls procedure to ensure best practice guidelines were followed following a fall.” from the report
End of life training
minorNo one was receiving end of life care during the inspection. The manager said end of life training was available and planned to ask staff to complete it.
“The registered manager told us that end of life training was available which she was going to ask staff to complete.” from the report
- 01What changes have you made to the falls procedure since the inspection?
- 02How do you assess and respond to someone's risk of falling?
- 03Have staff completed the planned end of life training?
- 04How will you support my relative's personal goals, hobbies and independence?
- 05How will you involve my relative in decisions about their care and support?
This was an unannounced inspection covering all five CQC questions, including the premises and the care provided. This explanation was written from the published report of 18 October 2019 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 Lodge
Each visit the CQC has published, newest first, back to the day the home was registered.
- July 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018
Registered with the Care Quality Commission on 4 September 2018.
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.
Weigh the report against the rest
Fees, photos and reviews from families
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36 live-in carers within about an hour of Newcastle upon Tyne
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,160 a week. 30 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.