Pembroke House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed safely, management of the premises and equipment and staffing.

This service scored 41 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although the provider had carried out detailed investigations into complaints from people and relatives, it was not clear how learning had been put in place and cascaded to staff. For example, the provider had received serious complaints about people missing prescribed medicines in the summer of 2025. The provider told CQC that systems had been put in place to address the investigation findings. However, we saw that the changes had not been embedded into practice and medicines continued to be a serious issue when we assessed the service.

Accidents and incidents had been reviewed by the management team and actions had been taken. For example, where people had fallen a number of times they had been referred to the falls team. People with wounds and pressure injuries had also been referred to the tissue viability nurses. When incidents and accidents occurred, people received medical help where needed. A staff member told us about an incident that had occurred the day before when a person fell. They said, “Information is shared between the staff who were involved, but not always with everyone. Communication is poor.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider had an electronic care planning system. This enabled the staff team to create hospital passports when these were needed. A hospital passport helps people to give hospital staff and other services important information about them and their health when they go to hospital. A relative raised concerns about poor communication and a lack of effective processes to ensure important documentation accompanied the person to hospital appointments. On more than 1 occasion, essential information such as DNAR [do not attempt cardiopulmonary resuscitation] and other health related documentation was not available for the hospital to review as it had not been given to the person. This required the relative to repeatedly contact the service for it. This caused frustration for both the relative and the person using the service.

People were supported to maintain their health and attend appointments, both inside and outside of the service. Where routine health checks were undertaken people had support from staff who they know well to understand what was happening.

The service had maintained regular contact with local authority social workers. This included ongoing work with the GP practice and other health and social care professionals. Staff told us they escalated concerns to nursing staff within the service and to the GP when needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe and were protected from harm. Safeguarding policies included information about safeguarding children from abuse. Safeguarding training included safeguarding children. This is because staff in care services come into contact with children as part of their work. The management team had reviewed processes and learnt lessons from safeguarding incidents. We observed interactions between staff and people during our visits. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Staff told us they were confident to speak up if needed. A staff member said, “I have done safeguarding level 2 adult and child, we do this once a year. If I witnessed abuse, I would pull the staff out of the room and then report it to the manager and follow the safeguarding protocol. I do feel it would be acted on, I could raise it higher in the organisation, and I could escalate it to the local authority and CQC.”

People told us they felt safe. A person said, “Yes, I do feel safe. I have recently had a new alarm system fitted after waiting approximately eight weeks for it to be installed.” Another person told us, “I have not felt safe until recently. My daughters have had to become involved.” A relative told us, “I feel they are safe there. There was an incident when my mum got out of the building, but I put that down to her dementia. Staff handled it very well and spoke to us about what had happened. She followed somebody out of the building. Since then, measures have been put in place to help keep her safe and I am happy with what has been done.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. DoLS applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. Systems to review these were also in place.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were not always robust and did not provide clear guidance to staff on how to work with people and how risks in relation to health and social care could be mitigated. For example, there were no epilepsy care plans or risk assessments in place and no instructions for staff in relation to potential seizure triggers, type of seizure activity that was usual for the person, what actions to take and when to escalate. There were no risk assessments in place in relation to day-to-day activities like showering, bathing, going out and no mention of SUDEP (Sudden Unexpected Death in Epilepsy).

People who were at risk of pressure injuries were not always repositioned in line with their care plans which increased the risks of injuries deteriorating. People’s emotional support care plans and risk assessments did not always provide guidance for staff on what action they should take to support people when they became anxious and distressed. People who were at risk of constipation were not always effectively monitored and provided with as and when required laxative medicine when they needed it. Some people were prescribed blood thinning medicines which increased the risk of bleeding. There were no risk assessments or instructions for staff about handling the person gently or what specific things to observe for, such as bruising, blood in the urine or what action to take if they sustained a cut or bruise.

We could not be assured that staff knew about people’s assessed choking risks. Some people had been seen by the Speech and Language Therapy teams (SaLT), and modified diets had been recommended. Staff told us no one had modified diets due to choking risks. However, we saw people receiving modified food during the lunch service showing that SaLT guidance was being followed. Staff told us this was personal preference and not due to assessed needs.

Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. However, these were not always complete and had not always been updated when people’s needs had changed. A staff member told us, “I haven’t seen a PEEP recently, we as staff are aware of who needs full evacuation and who needs to be in a safe space.”

Most people told us they felt safe and had equipment they needed. A person told us, “Bed has pressure mattress, it’s really comfortable.” Another person said, “I reached a point where I could no longer cope at home. I had visited Pembroke House previously, liked the staff and wanted to come here. I needed support and I feel safe living here.”

People were supported to move around the service safely and were supported to spend time where they chose. Staff told us about safe ways of working with people which demonstrated they knew them well.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Some building related checks and tests had not been completed regularly to keep people safe from harm. We found an electrical cupboard open and unlocked on the dementia unit of the service which had not been detected or reported. We reported this to the management team and action was taken to address this on day 1 of the site visit.

We found an assisted bath had not been LOLER (Lifting Operations and Lifting Equipment Regulations) checked during the 6 monthly LOLER checks. This meant the provider could not be assured that it was working safely. After the assessment the nominated individual told us the assisted bath, 'Was in the process of being decommissioned and wasn't in use. LOLER checks were stopped when the bath was taken out of service.'Some window restrictors were missing around the service; these had been detected in the provider’s checks and action to undertake this work had been arranged.

The fire service had visited the service in December 2025 and issued a deficiency notice, some actions to address these concerns were still outstanding, which evidenced timely action had not been taken to reduce fire risks in the service.

Water temperatures had been checked frequently, however the checks on thermostatic mixer valves only showed that water temperatures had been checked in communal bathrooms and sinks and not in people’s bedrooms. This meant the provider could not be assured that the water was at a safe temperature. Providers are required to flush water from empty rooms and outlets rarely used on a weekly basis to prevent the build-up of legionella in the pipes. We observed that there was a record of the water flushing undertaken on 11 June 2026. However, there were no previous records found to evidence this had been done regularly to keep people, visitors and staff safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People, relatives and staff reported there was not enough staff to meet people’s needs safely, particularly at night when only 1 staff member was allocated to work on the top floor (despite some people requiring 2 staff for support at night) this led to staff leaving another floor to assist with care and support which then left those floors short. A staff member said, “There is not enough staff on shift, we have more residents with higher needs on Pacific which makes things difficult. There is a lot going on, we do our best to follow the care plan, but with so much going on it’s not always possible, when you were here on Tuesday for example, we missed a reposition for a resident.” A relative said, “Staffing is the biggest issue. There is a lack of supervision, at weekends there is no management around. There never seems to be enough staff, there is only 1 nurse for the whole home.” A person told us, “When I press the call bell they don’t always come quickly. They say there are staff shortages.”

People, relatives and staff reported that there was high agency use. The rotas confirmed this. The management team told us that they used regular agency staff. Staff told us where regular agency was used it worked, however this was not always the case. This had impacted people as people told us that not all the agency staff knew them well. The management team told us recruitment was underway to fill vacancies. The provider used a dependency tool to work how staffing numbers to meet people’s needs. This tool had not been consistently reviewed and updated when people had been admitted to the service or left the service. The most up to date copy of the tool which had been reviewed in July 2026 showed one of the units had less staff that the tool stated they needed and other units within the home had slightly more. The management team stated that since our site visit, they had moved some people with higher needs from the Oak unit to meet their needs better.

Staff told us they had received training to meet people’s needs, training records showed that most staff have undertaken their mandatory training. The training records listed 82 staff; not all staff had attended safeguarding children which was required as children regularly visited the service. The nominated individual for the provider told us that 59 staff worked providing direct care and support (including nursing) to people. Only 27 staff had completed bed rail safety training, despite supporting many people who had bed rails in place. Only 67 staff had completed epilepsy training, despite people living with epilepsy. Only 13 staff had attended sepsis training, 50 had attended skin integrity training and 7 had attended slips trips and falls training. The management team had been encouraging staff to attend food and hydration training. A further 13 staff needed to complete this. Due to the issues identified in the assessment, the management team told us they had planned to run 2 half day training sessions on care planning and risk assessment for staff with responsibilities to complete these.

Staff had been safely recruited. All required checks had been carried out, and documents were all in-date. The information helps employers make safer recruitment decisions. Nurses were registered with the Nursing and Midwifery Council. The provider had made checks on their personal identification number, registration status and renewal date.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. There were infection control concerns in the medicines rooms, with dressings and stock stored in a cupboard under a foul smelling sink which had been leaking. The hand sanitising facilities around the service were empty and staff told us they had been empty for several months. The manager told us they had issued individual hand sanitisers to staff. However, it was not clear how this would protect people and visitors to the service as there were no hand sanitising facilities around the service for visitors. We spoke with the management team about this who added it to their action plan for the service.

The provider had a daily cleaning programme in place. The service employed housekeeping staff to carry out daily cleaning. Cleaning schedules of people’s rooms were in place. Cleaning schedules for other areas in the service, for example, communal areas, were in the process of being developed. Infection control audits were completed regularly and actions taken if any issues were found. Relatives told us, “When visiting, the home is very clean. The domestic staff are always cleaning” and “I have seen them cleaning her bathroom regularly.” A person told us, “Every day they clean.” Another person said, “The cleaning staff do a good job. They clean my room and toilet every day.”

The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. The kitchen areas were clean and well managed. We observed that the staff were using PPE effectively and safely.

Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. Staff said, “I wear full PPE and dispose of things appropriately” and “I use PPE and follow the infection control procedures.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The service had systems and processes in place for ordering, administering, storing and disposal of medicines however, staff were not always following these.

People were not always receiving their medicines as prescribed, we saw evidence of people missing several doses of their regular medicines such as antiepileptics, inhalers, Parkinson’s Disease medicines, pain relief and eye preparations because they were asleep or continuously refusing. Although the clinical lead told us the service were in the process of reviewing some people’s medicines with the GP, this was mainly for ‘when required’ [PRN] medicines.

Care plans were not always up to date or in place for specific health conditions such as Parkinson’s Disease and epilepsy. There was no guidance in place to inform staff how to respond to a person having a seizure or information about people's Parkinson Disease presentation or what to look for if their symptoms were uncontrolled. Where there were specific instructions to support people to take their medicines, for example when people refused their medicines, staff were not always following these. We could not be assured staff were always taking steps to ensure people received their medicines or escalated concerns about people not taking their medicines. There was a risk of people being harmed, experiencing a decline in their health and experiencing symptoms their medicines were prescribed to treat.

Records to support safe administration of medicines were not always available or up to date. Staff did not routinely record where medicated patches were applied to the skin, to ensure the patch was applied in line with manufacturers instructions or complete a daily check to ensure the patch was still in place. This meant people could be at risk of skin irritation and overdose due to a build-up of medication under the skin if patches are being reapplied to the same areas to frequently. We raised this with the clinical lead who put a new system in place straight away.

We could not be assured staff were trained and competent to administer medicines. Training records showed staff had received training however, this was not always demonstrated during the inspection. When asked, the clinical lead did not provide evidence of staff member’s current competency assessments. Governance arrangements and oversight of medicines was not robust. Audits undertaken had identified areas for improvement however, it was unclear when the audit had taken place, and no action plan was created to show how and when improvements would be addressed. Some of the concerns we found at the inspection had not been identified by the new management team. We could not be assured people were being kept safe and timely actions were being taken to improve the service.