Pembroke House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The recording of care notes was inconsistent and sometimes lacked detail, with statements like, ‘All care given as per plan’. Where people needed their food intake recorded for nutritional purposes, these lacked detail of what was eaten and how much. People had oral health care plans in place, but recording of actual care was lacking. In some cases, ‘Refused oral care’ was documented, but there was no evidence that this had been followed up on or any actions taken.

People had very detailed biographies at the front of their care plans, but the plans contained little detail about how staff should meet a person’s individual needs and safely manage or mitigate any risks. Care plans lacked detail in several areas, including food and fluid recording, repositioning, personal and oral hygiene and social care / interactions / activities. Care plans lacked guidance for staff. Care plans around bowel movements lacked detail in relation to what was normal for each person. For example, whether the person opened their bowels daily, every other day and what staff should do if they had not opened their bowel, such as utilising foods and natural remedies to act as a laxative or when to escalate for PRN medicines or referral to the GP. A staff member said, “I feel that care plans are not updated enough. We have someone on the middle floor who came in bedbound and very unwell, but his care plan says he walks around.”

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Information was shared with staff during handover regarding any changes to people’s health or care needs. The service worked with other health professionals involved in people’s care. A staff member said, “One of the problems at Pembroke is communication. From handovers to important information, things are often passed on by word of mouth.” A relative had provided feedback online on a care home review page in January 2026, they said, ‘I do believe communication between the staff during changeover could be improved.’

Staff told us how they supported people and their relatives. We received mixed feedback from relatives about how they felt staff supported people with appointments and communicated well with GPs and health specialists to ensure people received continuity of care. Comments included, “I asked them to respond as dad wasn’t getting his prescribed medicines”, “I am confident the home would arrange appointments and healthcare support for her if needed” and “They are good at contacting healthcare professionals such as GPs and hospitals.”

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

There was a lack of dementia friendly signage and way marking around the service to direct and orientate people. There was no dementia friendly signage on doors such as toilets, bathrooms and shower rooms. Some people had been actively walking around the service. Staff were aware of people’s individual communication needs for example, people who may have hearing or visual impairments. There were some notice boards around the service which had some easier to read information on display.

Staff shared how they provided information and communicated with people. They also picked up on people’s nonverbal communication such as facial expressions, eye movement or use of hands (thumbs up or down). We observed a person was struggling to communicate effectively in the middle of the afternoon as they did not have their hearing aids in place. They explained that they had lost their hearing aids. Their care plan detailed that their hearing aid was locked away in their safe at night due to previous incidents where the person had disposed of it. Staff had not followed the person’s care plan to ensure the hearing aid was in place. A person told us, “A lot of agency staff struggle to communicate effectively.”

The provider told us in their information return which was submitted in January 2026, ‘An individual’s information and communication needs are identified and recorded as part of their assessment at their first interaction with the service and as part of the day-to-day routine interactions with their allocated team, resident meetings, and care review. This is then added to care plans for the staff to review and we have family who can review these care plans at any stage as they have access to the portal if they wish to. We have hearing loops in our lifts. Larger print if required. We have talked about listening versions for any residents in the future who may not be able to read or see.’

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The provider told us surveys will be sent to people and relatives annually and monthly residents’ meetings will take place. A relatives meeting had taken place in December 2025, the minutes of the meeting were poor, and it did not show who attended. Some people and relatives told us they had not always felt listened to. A person told us, “They listen like they will [respond] but nothing changes.” Another person said, “I am not always sure whether managers genuinely listen to residents. Because I am quite vocal and tend to speak up.” Another person told us they were listened to but “It can take a long time.” A relative said, “Dad is at risk again and again, it had been going on for some time before I complained. I am not happy with Pembroke’s response, and I have told them this.”

Complaints processes were available. Complaints records showed that complaints had been responded to and action had been taken. Some people and relatives had not been satisfied with their responses. People and relatives gave us mixed views as to whether concerns and complaints were listened to. We directed these people to the Local Government Ombudsman to escalate their complaints.

The provider made sure that people could access the care, support and treatment they needed when they needed it.

The provider had a clear policy on accessing the service. The provider website stated, ‘Priority is given to those who have served as Warrant Officers or below in the Royal Navy or Royal Marines and their wives, husbands, widow(er) or civil partners. This includes service with the Royal Naval Reserves. Depending on availability of rooms, consideration may also be given to other applicants.’ A relative said, “Dad is proud to be in a military care home, he is a proud veteran.”

Staff told us the service utilised volunteers in the service to support with some activities, trips and engagement. A relative told us they had found volunteers had been utilised to carry out observations and checks of their loved one in place of staff.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

People had access to gardens and some access to community, religious services took place frequently and some people were supported to access the local community on occasions. Some people told us these trips took place less frequently now due to staff availability and a lack of drivers to drive the minibus. Staff told us that only people with no care or mobility needs were supported to attend trips and activities in the community. People with care and support needs as well as mobility needs were not supported to go out on trips and so did not have the same opportunities as others. We were not provided information by the management team or provider as to why people with care and support needs had been restricted in this way.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Some people had a DNACPR (Do not attempt cardiopulmonary resuscitation) form in place. This is an advanced decision not to attempt CPR. It is not about other treatments or care. Some people had ReSPECT (Recommended Summary Plan for Emergency Care Treatment) forms in place. A ReSPECT form records a person's wishes about a range of care and treatments.

End of life care plans were as comprehensive as the person wanted it to be and plans were clear in cases where people had chosen not to discuss this element of their care. The service provided some care to people at the end of their lives. Staff told us that they worked to ensure people had effective support and pain relief to ensure people had dignified, pain free deaths. Medicines were available to keep them as comfortable as possible. Training records showed that only 24 staff had attended training to support people at the end of their life.