CQC report explained · a residential care home
What the CQC found at Pembroke Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind care and enough staff, but serious gaps in safety, medicines, training, records and management.
This was an unannounced focused inspection on 24 and 25 April 2023. Inspectors reviewed medicines, risks, accidents, care records, recruitment, training, premises and management systems. They spoke with people, relatives, staff and professionals.
The home was rated Requires Improvement for Safe, Effective and Well-led. Inspectors found weak checks on risks, fire safety, medicines, recruitment, staff training and records. Some incidents were not investigated or reported properly. Care plans did not always give enough information about people's individual needs.
People and relatives generally described staff as kind and caring. Staff numbers were considered sufficient, people received meals and healthcare support, and families said communication was good. However, the overall rating fell from Good in 2019 because the provider had not acted on an earlier recommendation about audits of care and training.
Kind relationships
People and relatives described staff as kind, caring and respectful. Inspectors also saw positive relationships between people and staff.
“People and relatives were positive about staff being kind, caring and respectful” from the report
Staffing levels
Staff and professionals said there were enough staff to provide care safely. Inspectors also saw call bells answered promptly during the visit.
“The service had enough staff to provide care and support to people.” from the report
Healthcare support
People's changing health needs were monitored and referrals to health professionals were made in good time. Relatives said they were kept updated about their family member's wellbeing.
“People were referred to various health professionals in good time to address any health or changing needs.” from the report
Risks and fire safety
seriousSome risks were not properly assessed or managed. Fire safety checks, evacuation information and checks for legionella and scalding could not be evidenced.
“This meant people and staff did not have clear guidance to remain safe if there was a fire in the building.” from the report
Medicines
seriousSome medicines prescribed when needed did not have clear instructions for staff. Medicine storage temperatures were not monitored.
“People's medicine was not always managed safely.” from the report
Staff competence and recruitment
seriousSome recruitment checks were completed after staff started work, and one DBS check was missing. Training and competency checks were incomplete, including dementia training for 17 staff.
“This meant people were put at risk of not always getting appropriate and safe care and support.” from the report
Care records
needs fixingCare plans did not always reflect changing needs or explain how staff should support people. Records about capacity, consent and decision-making were also inconsistent.
“The provider did not ensure people's care and support needs were identified and recorded to ensure the service could meet their individual needs.” from the report
Management oversight
seriousThe provider had not carried out quality checks and audits for some time. It also lacked evidence of learning from incidents and had not gathered recent feedback from people, relatives and staff.
“The management team told us that quality assurance checks and audits had not been carried out for some time now.” from the report
- 01What has been done to complete fire safety checks, fire drills, evacuation plans and the fire risk assessment?
- 02How are medicines prescribed for use when needed now recorded, administered and monitored?
- 03Which staff training and competency checks were outstanding, especially dementia, medicines, safeguarding and moving and positioning?
- 04How are care plans being updated when a person's mobility, behaviour, capacity or health needs change?
- 05What quality audits and feedback systems are now in place, and how will you show that incidents are investigated and lessons are acted on?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings were not given in this report. This explanation was written from the published report of 17 August 2023 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, May 2019
Rated Good overall; inspectors found kind, personalised care, but leadership needed to improve records and training.
This was a planned inspection on 25 March and 2 April 2019. The inspector reviewed five care files, medicines, risk assessments, training and recruitment records. They also observed care, spoke with six people, two relatives, staff and a visiting professional.
The home was rated Good for Safe, Effective, Caring and Responsive. People told inspectors they felt safe and were treated with kindness and respect. Care was tailored to people's needs, interests and choices. Staff supported people's independence, health, activities and relationships.
Well-led was rated Requires Improvement. Some care plans and risk assessments were not kept up to date, and some staff refresher training had not been completed. Managers started corrective action during the inspection, including reviewing records and setting training deadlines.
The overall rating remained Good, the same as at the previous inspection published in December 2016. CQC said it would continue to monitor the home.
People felt safe
People told inspectors they felt safe. Staff understood safeguarding responsibilities and knew how to raise concerns.
“People told us they felt safe living at the service.” from the report
Kind and respectful care
Staff knew people well and supported them with patience, dignity and respect. Inspectors observed discreet and compassionate care.
“Staff were observed to be kind, considerate and approachable.” from the report
Personalised support
People were supported to retain their skills and independence, follow their interests and try new activities. Staff supported contact with family and access to the community.
“People were supported to follow their interests and encouraged to try something new, to promote their quality of life.” from the report
Supportive management culture
People and staff spoke highly of the management team. Inspectors found an inclusive culture that respected people's equality, diversity and choices.
“Pembroke Lodge, a family run business, had a long-standing registered manager in post, who along with the management team led the service's clearly person-centred, warm and caring culture.” from the report
Care records were not always current
needs fixingSome care plans and risk assessments did not reflect changing needs or were not reviewed when required. Managers started a review process during the inspection.
“Care plans and risk assessments were not always revised as required, although staff were able to accurately describe how to provide care and manage risk.” from the report
Refresher training was overdue
needs fixingSome staff training needed refreshing and had not been booked or completed within the required timescales. Managers allocated time for staff to complete it.
“Similarly training had not been refreshed in line with expiry dates.” from the report
Record-keeping needed improvement
minorRecords did not always show when they had been completed or document people's involvement in care planning. CQC recommended that the home review its governance systems.
“We recommend that the service review the effectiveness of their governance systems specifically in relation to documentation and training.” from the report
- 01Are all care plans and risk assessments now reviewed whenever people's needs change?
- 02Which staff refresher courses were overdue, and have they all now been completed?
- 03How do you check that records show people's involvement in decisions about their care?
- 04What changes were made after the inspection to improve audits of care records and training?
- 05How will you make sure staff continue to know people's individual needs if records are updated?
This was a planned inspection covering all five CQC questions and the care home premises and care provided; the service also supported people in supported living, where CQC looked only at personal care and support. This explanation was written from the published report of 30 May 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
4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- April 2013
Registered with the Care Quality Commission on 2 April 2013.
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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Most charge £1,010 to £1,270 a week. 86 can care for a couple. 12 years' experience on average.
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