We carried out a review of the data available to us about Pembroke House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Pembroke House, you can give feedback on this service.
About the service
Pembroke House is registered to provide people with nursing and residential care. It can accommodate up to 55 older people. At the time of this inspection there were 46 people living in the service. The service supports people with a wide variety of needs including those requiring minimal personal care to people with complex nursing needs. Accommodation is provided over three floors, with a number of lounges, dining rooms and a coffee shop.
The service provides care for former Royal Naval ratings, other ranks from the Royal Marines, their wives and widows and people who have had a connection with the Royal Navy. The Royal Naval Benevolent Trust (RNBT), a charitable non-profit making organisation, owns and manages the service.
People’s experience of using this service
People and their relatives told us that they experienced a service where staff were caring and respectful. Everyone said they would recommend the service to others. One person told us, “I would recommend people to come here; it is a pleasure. I would give them 11 out of 10”. Another person said, “This home is marvellous, and I could not have chosen better. The staff are excellent and nothing too much trouble. Staff are definitely well trained. My room is lovely, and my children are happy”.
People continued to be protected from the potential risk of abuse. Individual risks were identified and steps taken to reduce them. Staff had the guidance they needed to minimise harm to people whilst supporting independence.
Staffing levels were monitored so there were enough staff to meet people's needs. Recruitment practices were safe to ensure people were protected from the risk of unsuitable staff.
People continued to receive their medicines as prescribed by their GP. Medicines had been stored, administered, audited and reviewed regularly.
We were assured that the service could respond to COVID-19 and other infection outbreaks effectively.
Everyone said the service was well-led and that the manager and deputy managers were approachable. Systems to monitor the quality of the service provided, included gaining feedback from people who used the service.
The culture of the service was open and honest. Lessons had been learned when things had not gone the way that they should have gone. The management team were proactive in engaging staff in the service and as a result staff morale had improved. Staff felt well supported and listened to.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Good (published 9 August 2018).
Why we inspected
This inspection was prompted by our data insight that assesses potential risks at services, concerns in relation to aspects of care provision and previous ratings. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. This enabled us to look at the concerns raised and review the previous ratings.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We found no evidence during this inspection that people were at risk of harm from these concerns. The overall rating for the service remains Good. This is based on the findings at this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pembroke House on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Pembroke House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Pembroke House provides accommodation, residential and nursing care for up to 55 older people. There were three floors of accommodation in the premises providing nursing and residential care to people with varying needs. The ground floor accommodated people with dependent residential needs and the middle floor for people requiring complex nursing care. The top floor accommodated people who were quite independent, requiring minimal support with personal care. The service provides care for former Royal Naval ratings, other ranks from the Royal Marines, their wives and widows and people who have had a connection with the Royal Navy. The Royal Naval Benevolent Trust (RNBT), a charitable non-profit making organisation, owns and manages the service. There were 49 people living at the service on the days of our inspection.
At our last inspection in August 2016 we rated the domain of ‘Safe’ as requires improvement. There was a breach of regulations in relation to Regulation 12, Safe care and treatment. The provider did not ensure people’s medicines were administered and managed safely. Following the inspection, the provider sent us an action plan to show how they intended to improve the service and meet the requirements of the regulations. Two recommendations were also made in relation to good practice; that the registered manager ensures individual risk assessments benefit from having more attention to individual detail in order to provide the correct person centred guidance to staff and the registered manager sought training from a reputable source to ensure staff completing care plans understand the detail is crucial to providing consistent person centred care. At this inspection we found that the provider had made improvements in these areas.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
People were supported to have maximum choice and control of their lives in line with the principles of the Mental Capacity Act 2005. The provider had taken the necessary steps to ensure that people only received lawful care that was the least restrictive possible.
People gave us positive feedback about the service and told us they received safe, effective, caring, responsive care.
Staff provided caring and considerate support and respected people’s privacy and dignity.
People and their relatives told us they felt safe living at the home. They could tell us who they would speak to if they were worried about anything and they said they were confident they would be listened to. We spoke to staff who were able to tell us how they kept people safe. They understood their responsibilities in reporting any concerns they had and their own role in ensuring people were safe from abuse.
The provider followed safe recruitment practice. Essential documentation was in place for employed staff. Staff received supervision and said they were supported in their role. There were suitable numbers of staff to be able to provide the nursing and personal care people had been assessed as needing.
Registered nurses were employed to provide the professional expertise required to respond to people’s often complex care needs. Care staff were not expected to undertake cleaning or cooking duties as experienced chefs and domestic staff were employed. This meant care staff concentrated on providing the care people required.
An external company had been contracted to provide training for staff and a new training schedule was being put in place. All staff received the training they required to carry out their role well. Staff were very positive about the training provided and felt they were well equipped to carry out their role well. Registered nurses were supported by the provider to undertake training, ensuring their professional development continued in order to keep their registration up to date.
Nurses assessed people’s needs and identified risks, putting measures in place to manage these. Records were currently being transferred from a paper system to the new electronic system.
People’s nursing and care needs were assessed before moving into the service, by the registered manager and nurses to make sure they were able to cater for their individual needs. Following assessment, the nurses developed a care plan to record how to provide the care required, taking into account people’s individual preferences and choices. The information we saw being recorded on the new electronic system was person centred to support people well with all aspects of their care, including end of life care.
The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The provider understood their responsibilities under the Deprivation of Liberty Safeguards. People’s capacity to consent to care and support had been assessed and recorded within their care plans.
A new medicine administration system had recently been implemented and medicines were now well managed, stored securely and records showed that medicines had been administered as they had been prescribed.
People were supported to access health care services when needed. The provider worked in partnership with a range of healthcare professionals to ensure people received appropriate care and treatment.
People had sufficient food and drink and were provided with choices at mealtimes. Meals and mealtimes promoted people’s wellbeing, meal times were relaxed and people were given choices.
An activities coordinator and an assistant, planned activities each week and many months ahead. A band of very active volunteers were supportive of the activities programme enabling people to attend many events and visits outside of the service. Funding available through the provider’s charitable trust added to the resources available, including a fully accessible mini bus.
Complaints were investigated and responded to, as were accidents and incidents. The registered manager took the opportunity to analyse and learn from these in order to be able to improve the service provided.
Residents and relatives meetings were held so the registered manager could listen to concerns and ensure the involvement of people in the running of the service. Residents, relatives and staff surveys were undertaken to support the improvement of the service.
The registered manager had a range of auditing processes in place to monitor the quality and safety of the service. People, their relatives and the staff thought the home was well run and the registered manager was approachable and supportive. People and staff said the registered manager was present around the home many times a day and knew people and staff well.
The provider had developed effective links with organisations that helped them develop best practice in the service. The provider used effective systems to continually monitor the quality of the service.
There were systems and processes to enable lessons to be learned and improvements made if things went wrong.
Management systems were in use to minimise the risks from the spread of infection, staff received training about controlling infection and had access to personal protective equipment like disposable gloves and aprons.
The premises were well maintained, clean and tidy.
Pembroke House was registered to provide nursing and personal care services for up to 55 people. There were 52 people living at the home on the day of our inspection. The home provides residential and nursing care for former Royal Naval ratings, other ranks from the Royal Marines, their wives and widows and people who have had a connection with the Royal Navy. The Royal Naval Benevolent Trust (RNBT), a charitable non-profit making organisation, owns and manages the home.
Pembroke House was a pleasant building with a well set out parking area to the side and benches at the front to sit on, overlooking a park. There were three floors of accommodation in the home providing nursing and residential care to people with varying needs. The ground floor accommodated people with dependent residential needs and the middle floor for people requiring complex nursing care. The top floor accommodated people who were quite independent, requiring minimal support with personal care. On the ground floor a café area with tables and chairs opened on to a large well maintained garden at the back of the property with vegetable patch and greenhouse.
We last inspected the service on 18 May 2015. At that inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to Regulation 9, Person centred care, Regulation 10, Dignity and respect; Regulation 12, Safe care and treatment and Regulation 17, Good governance. Following the inspection the provider sent us an action plan to show how they intended to improve the service and meet the requirements of the regulations.
At this inspection we found that the provider had taken action to address the breaches from the previous inspection and had made many improvements to the service provided. However there continued to be some areas of concern around the safe management of people’s medicines.
There was a registered manager based at the service who had taken her post after the last inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People and their relatives told us they felt safe living at the home. They could tell us who they would speak to if they were worried about anything and they said they were confident they would be listened to. We spoke to staff who were able to tell us how they kept people safe. They understood their responsibilities in reporting any concerns they had and their own role in ensuring people were safe from abuse.
Medicines were not always managed safely. The records kept to document when prescribed medicines had been administered were sometimes poorly recorded with gaps that were unaccounted for. The recording of one person’s medicines had become confused and was recorded incorrectly. Guidance was not always available for staff regarding medicines to be taken ‘as and when necessary’.
There were suitable numbers of staff to be able to provide the nursing and personal care people had been assessed as needing. Agency staff had been used more often than the registered manager and staff team would have liked due to staff shortages. However, new staff had been recruited so there was an improvement in staffing and reduced agency usage. Registered nurses were employed to provide the professional expertise required to respond to people’s often complex care needs. Care staff were not expected to undertake cleaning or cooking duties as experienced chefs and domestic staff were employed. This meant care staff concentrated on providing the care people required. Safe recruitment processes were used when employing new staff to make sure only suitable staff were employed to work with people.
The registered manager had a training schedule in place and all staff received the training they required to carry out their role well. Staff were very positive about the training provided and felt they were well equipped to carry out their role well. Registered nurses were supported by the provider to undertake training, ensuring their professional development continued in order to keep their registration up to date.
Registered nurses assessed people’s needs and identified risks, putting measures in place to manage these. Some individual risk assessments provided only basic information when complex risks had been identified in the assessment. Some risk assessments needed to give more specific guidance to staff in order to provide safe, effective care. We made a recommendation about this.
People’s nursing and care needs were assessed before moving into the home by the registered manager and nurses to make sure they were able to cater for their individual needs. Following assessment, the nurses developed a care plan to record how to provide the care required, taking into account people’s individual preferences and choices. The information recorded in some people’s care plans was not person centred, leaving a gap in documentation how to support people well with all aspects of their care. We made a recommendation about this.
An activities coordinator and assistant planned activities each week and also many months ahead. A band of very active volunteers were supportive of the activities programme enabling people to attend many events and visits outside of the home. Funding available through the provider’s charitable trust added to the resources available, including a new fully accessible mini bus.
Complaints were investigated and responded to well as were accidents and incidents. The registered manager took the opportunity to learn from complaints received and incidents that had happened to be able to improve the service provided.
An active residents committee met every month to raise any issues people wanted. Residents meetings and relatives meetings were held so the registered manager could listen to concerns and ensure the involvement of people in the running of the service.
Residents, relatives and staff surveys were undertaken to support the improvement of the services provided in the home.
The registered manager had a range of auditing processes in place to monitor the quality and safety of the home. People, their relatives and the staff thought the home was well run and the registered manager was approachable and supportive. People and staff said the registered manager was present around the home many times a day and knew people and staff well.
We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the registered provider to take at the back of the full version of the report.
This inspection was carried out on 18 May 2015. The inspection was unannounced.
Pembroke House provides accommodation, nursing and personal care for up to 54 former Royal Naval Ratings, other ranks from the Royal Marines, their wives and widows, and people who have had a connection with the Royal Navy. The Royal Naval Benevolent Trust, which is a charitable non-profit making organisation, owns and manages the home. People had a variety of complex needs including people with mental and physical health needs. Accommodation was provided over 3 floors. There was a passenger lift to assist people to move between floors.
The service had a registered manager. The provider informed us that they had been absent for a number of weeks before our inspection. The Head of Care was managing the service in the absence of the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2014 and associated Regulations about how the service is run.
During this inspection we looked at how the provider was meeting the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which came into force on 1 April 2015. During this inspection, we found some breaches of regulations relating to fundamental standards of care. We asked the provider to take action in relation to risk management; the management of medicines; privacy and dignity; quality assurance systems and record keeping.
During our inspection, people made complimentary comments about the service they received. People told us they felt safe and well looked after. However, our own observations and the records we looked at did not always match the positive descriptions people had given us. Relatives told us they were satisfied with the service.
Effective systems were not in place to enable the provider to assess, monitor and improve the quality and safety of the service or identify and manage all the risks to people’s safety. Where shortfalls were identified during audits by the manager, action was not taken in a timely manner to improve the quality of the service.
Some people had not received their medicines as prescribed. Suitable arrangements were in place for managing medicines, but the recording of medicines did not follow guidance issued by the National Institute for Health and Clinical Excellence.
Staff did not always respect people’s privacy and dignity. Bedroom doors were left open throughout the home when people were in bed or in their rooms. Staff were not always discrete in their conversations about or with people. There was no evidence that people were able to choose to be supported by a male or a female member of staff.
The planning of care for people focussed largely on their physical needs. There were no care plans relating to people’s emotional, spiritual or mental health needs. There was limited information about people’s likes and dislikes or lifestyle choices. This showed that people’s care was not planned in a personalised way.
People and staff felt there were usually enough staff deployed in the service. The provider did not have an up to date analysis of people’s needs to assess how many staff were required and to arrange for enough staff to be on duty at all times. We have made a recommendation about this.
Staff felt well supported by the provider and the management team. New staff received induction training. All staff had essential training and opportunities for additional training, Each member of staff had an annual appraisal to assess their performance and any further training needs. Regular supervision sessions were not scheduled with each member of staff. We have made a recommendation about this.
People were complimentary about the food and were provided with enough to eat and drink. Choices of menu were offered each day. Some improvement was needed at mealtimes to make sure people ate in a pleasant and homely environment, and had as much control as possible over the content of their meals and portion sizes. We have made a recommendation about this.
There was a system for managing complaints about the service. People were listened to and knew who to talk to if they were unhappy about any aspect of the service. People knew about the procedure for making a complaint about the service. The complaints policy was out of date and did have current information about external services people could complain to. We have made a recommendation about this.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People were not assessed as lacking capacity to make decisions for themselves at this service. Staff were supporting people following decisions they had made which were not in their best interest. Not all staff had received training in the Mental Capacity Act 2015 or DoLS to enable them to do this effectively. We have made a recommendation about this.
Staff were generally kind and caring in their approach and had a good rapport with people. The atmosphere in the home was calm and relaxed and there were lots of smiles and laughter. Safe recruitment procedures were followed to make sure staff were suitable. People were safeguarded form abuse.
People were supported to maintain their relationships with people who mattered to them. Visitors were welcomed at the service at any reasonable time and were complimentary about the care their relatives received. People were consulted through resident’s meetings and their views taken into account in the way the service was run.
You can see what action we told the provider to take at the back of the full version of this report.
We found that the home was well presented and clean in all areas. People said that they liked living in the home, and gave us very positive comments such as, 'It is superb. Everything runs extremely well. I have been here for two years'; and 'It is always spotlessly clean, they pay attention to detail with everything'; and 'There are loads of things to do if you want to join in.'
We found that people felt that their privacy and dignity were respected and they were encouraged to retain their independence with things they could do for themselves.
The care plans demonstrated that reliable procedures were in place for managing people's health and personal care.
People said that the food was 'Very good' and we saw that there was a good variety for meeting people's nutritional needs.
We found that medicines were managed and administered correctly.
The home had appropriate recruitment procedures in place to ensure that staff working in the home were suitably skilled and qualified for their job roles.
People's views were listened to and taken into account in the ongoing management and monitoring of the home's progress.
Comments from relatives of people that used the service included 'Thank the staff and nurses for their loving care', 'The staff who attended us here were so caring and attentive', 'Thank you for taking such good care of X' and 'We want to thank you all for the care and attention you gave X, so clean and all the staff were so caring and friendly'. Other comments included 'Enjoyed visits to the garden on sunny days' and 'The gardens are beautiful in all seasons'.
We judged the service to be compliant with Outcomes 1, 4, 7, 14 and 16. We found that the premises were well maintained and that the newly completed extension was being enjoyed by the people that used the service. They said that they liked the facilities of the shop and hairdressing salon. One person told us that they liked their new well equipped bedroom.