Pembroke Lodge

Updated 17 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Inspection was carried out by two inspectors. Another inspector made calls to staff to gather feedback. An Expert by Experience contacted the relatives of people who use the service to gather their feedback as part of the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Pembroke Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pembroke Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection a registered manager was not available to support the inspection. We were supported by two deputy managers and the care manager. The care manager was overseeing people’s care and support, and staff management as part of support to the deputy managers and the registered manager. We will refer to them as ‘the management team’ in the report.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Prior to the inspection we looked at all the information we had collected about the service including previous report and information from the local authority. We looked notifications the provider had sent us. A notification is information about important events which the service is required to tell us about by law. We reviewed the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to 2 deputy managers, the care manager and 2 people who use the service. We observed interactions between staff and people living at the service during mealtimes, activities, in communal areas and in their rooms. We reviewed a range of records relating to the management of the service, for example, records of medicines management, risk assessments, accidents and incidents, quality assurance systems, and maintenance records. We looked at 7 people's plans of care and support and associated records. We looked at 9 staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed. After the site visit, we continued to seek clarification from the management team to validate evidence found. We looked at further records and evidence including quality assurance records, training data, meeting minutes, and policies and procedures. We spoke to 8 relatives about their experience of the care provided to their family members. We also spoke

Updated 17 August 2023

About the service

Pembroke Lodge is a residential care home, providing accommodation and personal care to up to 20 people, who can reside in both single and double occupancy rooms over three floors. The service provides support to people living with dementia, mental health needs, physical disability, sensory impairment and older people. At the time of our inspection there were 17 people using the service.

People’s experience of using this service and what we found

The provider did not always operate effective quality assurance systems to oversee the service and identify shortfalls in the quality and safety of the service or ensure expected standards were met. The provider did not ensure clear and consistent records were kept for people, their care, and the service management. The provider did not always ensure management and mitigation of risk to people and their care. Safe recruitment processes were not always used to ensure staff were suitable to support people. The management of medicines and premises was not always safe. Not all staff were up to date with, or had received, their competency checks and mandatory training. When incidents or accidents happened, it was not always clear they were fully investigated, and if any lessons were learnt or themes and trends reviewed. The provider did not inform us about notifiable incidents in a timely manner. The provider did not demonstrate they understood and maintained clear records to meet requirements of duty of candour. People's, relatives' and staff’s feedback were not sought to drive continuous improvements in the service.

People’s families and other people that mattered felt they were involved in the planning of their care. However, care plans and related documents had some information about people, but it did not always contain information specific to people's needs and how to manage any conditions they had. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. However, the policies and systems in the service did not support this practice and needed improvements.

We have made a recommendation about the premises being suitable for people living with dementia and maintaining accurate records in regard to people’s capacity assessments, consent and decision making.

People and relatives were positive about staff being kind, caring and respectful and our observation confirmed this during the inspection. People and relatives felt they could approach the management team with any concerns and felt they had good communication and relationships with the service.

People had meals to meet their nutrition needs. Hot and cold drinks and snacks were available between meals. Relatives said they were kept informed about their relatives’ health and welfare. People said they were safe living at the service and relatives felt their family members were kept safe. Staff told us they understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately. The management team was working with the local authority to investigate safeguarding cases and make other improvements.

Staff members felt staffing levels were sufficient to do their job safely and effectively. Staff had supervision and appraisals, and team meetings. The management team appreciated staff’s work, contributions and efforts to ensure people received the care and support they required. Staff felt they could approach the management team for support and advice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was good (report published 30 May 2019). At our last inspection we recommended that the provider had to review the effectiveness of audit systems specifically in relation to care and training. At this inspection we found that the provider had not acted on the recommendation made and had not made improvements.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We received information of concern in relation to people safety and how it was managed as part of quality assurance. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pembroke Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to quality assurance; risk management; notification of incidents and changes to statement of purpose; record keeping for care and support planning; duty of candour; management of medicine; staff training and competence, and recruitment at this inspection. We have made a recommendation about the premises being suitable for people living with dementia, assessing capacity and seeking consent.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.