Pembroke House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to person-centred care.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them. People had their needs assessed before moving to the service. These assessments were used to develop the person’s care plans and make the decisions about the staffing hours and skills needed to support the person. The assessment included making sure that support was planned for people’s diversity needs, such as their religion, gender, marital status, culture and their abilities.

Assessments included information about what people could do for themselves. Each person’s care plan and assessments were also reassessed once a month as part of the ‘resident of the day’ process. This ensured that every person’s care plan and risk assessment were updated at least monthly. However, we found that some care plans and assessments conflicted as they had not always been updated in a timely manner when people’s needs changed. This had the potential to impact on people’s care and support because agency staff were being used and new staff were starting to work at the service.

People were able to recall being involved in their assessments and care planning process. A person said, “I have seen my care plan. They have not reviewed it with me recently, although they may have updated it themselves.”

A relative said, “On the 19th of every month she is 'Resident of the Day', her care plan is updated and she gets afternoon tea. It is something we now look forward to.” We observed that staff knew people well.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The provider had systems and processes in place to meet people’s nutrition and hydration needs. However, records were inconsistent and showed that some people who were at risk of dehydration were potentially not having enough fluids to keep well. There did not appear to be any robust monitoring of people’s fluid intake or output. Staff told us people did not have a target fluid intake amount set, unless they were on a fluid restricted diet. The service did not have a robust method of ensuring people were adequately hydrated. A person’s jug was two thirds full at 12:40, the liquid in the jug was at the same level at 16:44. This was a person at risk of dehydration according to their risk assessments. We observed some people being prompted and encouraged to drink throughout the day. A staff member said, “We have handover, if someone has had low fluids, seniors encourage fluids. We can give ice cream and yoghurts if fluids are low too.”

Care plans and risk assessments described what modified diet people were prescribed and the care plans followed The International Dysphagia Diet Standardisation Initiative (IDDSI) framework. The guidance was also available in the kitchen to staff responsible for preparing, cooking and serving meals. Kitchen staff and those responsible for supporting people with their food had a good understanding of people’s assessed needs in relation to allergies and food intolerances. Staff told us they helped people to make their meal choices if they needed it. We observed staff asking people what food choices they would like. Meals had been recorded for most people, but records were not descriptive enough to monitor or assess people’s food intake.

We received mixed feedback about the food. Comments included, “The food has definitely gone downhill, lunchtime there is always a choice, the quality of food is not good, there are agency cooks, we sometimes go and see them. I buy tins of veg as I find the veg undercooked”, “Food is great, they listen to likes and dislikes, and I get a choice”, “I think there have been some catering issues in the past. The food has improved over the last couple of weeks and I believe they now have a new caterer”, “The food is not always the best, but it is alright”, “Sometimes the food looks nice, but it can be too salty” and “The food has not been as good since the cook left. Agency cooks are often being used, and the food is sometimes poorly prepared. There is plenty of food available, but it is not always cooked well.”

The provider worked well across teams and services to support people. They did not always make sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services. The provider had a clear process in place to escalate health concerns; this was not always within a timely manner. Staff worked with health professionals to ensure people got the care and support they needed.

Hospital passport systems (which we have reported about in Safe) were not always used to ensure people’s health and social care needs were known to clinicians. This put them at risk of harm. Some people had experienced delays in escalating health concerns to relevant health professionals. For example, medicines trained staff had failed to report to the GP that some people weighed less than 50kg which impacted on the amount of paracetamol they could be administered. People had been given too much paracetamol for their weight.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Some people’s records showed staff had not escalated concerns to their GP in a timely manner. Records showed MUST (malnutrition universal screening tool) scores had been recorded for most people and there was a list on each floor of people who needed to be weighed regularly. People who needed regular weight monitoring had been weighed as per their plan. However, when people experienced on-going weight loss, it was not clear from the records, what actions had been taken, if any such as a referral to a dietician.

Where people had developed wounds, safeguarding records had been completed, and wound management plans were in place with progress notes and photographs. This enabled nursing staff to monitor the wounds and escalate when required. Body maps were used to identify the location of the wounds and there was evidence of involvement of the community tissue viability nurse team.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

A relative told us about their experiences of dealing with the service to ensure their loved one’s needs were met. They shared an experience which happened in January 2026 where nursing staff had not identified or escalated a visible rash and wound to their loved one’s leg, which had been measured by nursing staff that morning. They felt action was only taken because they had insisted on it being raised with the GP. They told us, “The other day he had an open wound on his toe, again they [nursing staff] had measured the leg and had not noticed.

The provider had carried out an investigation into a complaint and found (in April 2026) that, ‘There were also inconsistencies in clinical monitoring and escalation. While appropriate action was taken at the point of acute deterioration, earlier signs of decline were not always clearly recognised, documented, or acted upon.’

The management team told us in their information return which was submitted on 31 January 2026, ‘We have an established relationship with the Dementia Crisis Team, who we contact for advice or when a resident’s behaviour or mental health presents challenges. The team provides onsite assessments, recommendations, and guidance for both staff and relatives, helping us to manage complex situations safely and effectively.’ Nursing staff and other staff told us there were good links with other health professionals such as SaLT (Speech and Language Therapy), physiotherapy, the GP and TVN (Tissue Viability nurse). Trained nurses within the service reviewed and updated people’s clinical records daily if they required nursing care.

People told us staff worked with GP’s and health professionals to meet their health needs. A person said, “I have seen the nurse once since I was here. Have changed from my regular doctor to this one.” Other people told us, “I have someone who helps with my nail care” and “I have access to a doctor when needed, although I have not seen a dentist.”

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

We checked whether the service was working within the principles of the Mental Capacity Act (MCA). The service worked within the principles of the MCA. When people were assessed as lacking capacity to make decisions appropriate procedures were followed to ensure principles within the MCA were followed. Decisions made were appropriately documented to demonstrate who had been involved in the decision. People had signed consent forms within their care records. Some people had bed rails in place. Where people could not make this decision for themselves a best interest decision had been made and documented which included input from relatives. Where people were able to make their own decisions and chose to have bed rails, their decision, along with the risks were documented in their care records. Bed rails that were in use were safe.

People's ability to consent to care and support had been assessed. Care was person centred, people were offered choices throughout the day, and most people told us they felt listened to and their views and opinions were important to staff. A person said, “We are given lots of choice with food. I am able to go to bed whenever I want. I have even been getting up during the early hours to watch the Formula One Grand Prix. They generally allow me to make my own choices. If they think a choice may not be the best one, they will advise me.”