Pembroke House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 50 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff told us that the culture of the service has been poor, however, they recognised that the new management team were working to address this and improvements were starting to be made. Comments included, “There has definitely been a culture change since the new management, we can discuss service users and personal things, and they listen and are more open. They are making lots of changes, we have not had a staff meeting since the new team started, we are expecting them”, “The new management team are looking at this now to be an open culture” and “I feel the culture used to be closed. With the previous management team, people had favourites and staff were frightened to speak up. I have seen some changes recently and I now feel more able to speak out.”

A relative told us, “There was a bullying culture. I had been reporting it to them for a year.”

The nominated individual for the provider has written to CQC since the assessment site visits to share the provider’s plan and set out the ethos, they recognised that this was aspirational at the current time but set out how they will achieve improvements.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. However, there was no registered manager in post when we carried out our assessment. The previous registered manager had left several weeks before. There was an interim management team in place, and the provider was actively recruiting to the registered manager position. The provider told us after our site visits that they had recruited a new manager on 1 July 2026. At the time of the assessment the application to register the new manager with CQC had not been completed. The new management team were working hard together to address the serious issues identified across the service. The management team reported they had good support from the nominated individual for the provider and the head office. A relative told us, “RNBT (Royal Naval Benevolent Trust) stepped away from monitoring Pembroke, it got worse and then families then escalated the issue, I do think change is at foot. Lots of change is needed, where things were so dangerous, they focused on those things, and it is getting slightly better.”

People did not always feel they could speak up and that their voice would be heard.

Staff told us how they would escalate concerns to the senior management team, the provider or outside of the organisation. Staff told us they had reported concerns previously to the registered manager and they had failed to deal with things. Only 53 staff had completed whistleblowing training. Some relatives told us that their previous concerns and issues had not been dealt with effectively. A relative told us, “They need a more robust whistleblowing procedure.”

Some staff confirmed they had attended some staff meetings. Staff meeting minutes evidenced that the last one had taken place in February 2026. The meeting records did not show who had attended and appeared to show reminders and instructions from the management team. Staff did not appear to be encouraged to voice their ideas for improvements and any concerns. Since the new management team had been in post, they had introduced a daily meeting with heads of department to get a shared understanding of what was happening in the service on a day-to-day basis and to support working together. A staff member said, “We have a daily meeting at 11, activities staff can’t attend as we have been too short staffed (plus it happens at the same time as the activities).”

The provider had HR policies in place to support staff including a grievance procedure. The nominated individual for the provider had become more involved in induction training for new staff in 2026 and had acted on concerns raised by staff that had been shared with them during the events.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. However, some staff reported they had not always been dealt with in a fair and appropriate manner, they felt they had not been listened to, had not been treated well by the registered manager and felt intimidated and unsupported. A staff member felt that the way they had been treated was due to their skin colour. They said, “I felt that was racially motivated. I felt it was sent to me because of my skin colour and that assumptions were made.”

Staff told us there was a culture change since the new management team had come in. They recognised it will take time to rebuild strong working relationships and trust.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s audit systems had not been robust or embedded. The new management team had put in place some new audits and these had been taking place in April and May 2026. Action plans from audits were detailed however they had no deadline dates of when actions would be completed. Audits had not highlighted the significant issues with medicines and deficits with care plans, risk assessments and records.

The provider had failed to complete checks and support to the service to ensure the service was safe and effective. The provider had commissioned external audits with a compliance organisation. They had carried out a mock inspection in April 2025, this identified that actions were required to improve; medicines management, risk management, lessons learned, infection control, lack of training for staff around health conditions, fluid records were a concern, as was a lack of oral care assessments. The mock inspection also identified that the audits were not robust as they had not identified what the compliance organisation had found. The provider had failed to put in place a robust response to the mock inspection findings. The same external compliance organisation carried out a check in March 2026 and found the service had deteriorated further, this showed a clear and marked deterioration across the board in four of the five areas. At our assessment we found significant concerns which evidenced timely and robust action had not been taken by the provider to improve the service.

Following the assessment the nominated individual for the provider wrote to CQC to set out the provider’s new plans to improve the service which included a new suite of audit systems and checks. This included a process of peer auditing between the provider’s other service. A quality manual had been created. The provider told us, ‘The events at Pembroke House have resulted in significant organisational learning for The RNBT. These lessons have directly informed the development of The RNBT Quality Monitoring and Governance Framework introduced in April 2026. The RNBT fully acknowledges the concerns identified by CQC, the independent inspections and the [person’s] investigation. Whilst governance arrangements were in place and concerns were escalated appropriately, The RNBT recognises that those arrangements did not identify the full extent of the issues that later emerged. The organisation has reflected carefully on this and has implemented significant structural changes to strengthen assurance, governance and oversight.’

People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so. The provider had displayed their last inspection rating on their website and within the building.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities, the local authority and through links with GPs. There were links with the local community, staff reported a veteran’s breakfast was held in Gillingham in May 2026 as well as children and young people attending the service as part of activities which people enjoyed. The new management team were keen to build on relationships and had met with the pharmacy and GP for support to drive improvement for people. They were also keen to develop partnerships with other local services, support networks with other registered managers, such as local authority forums and gain support from organisations such as skills for care.

The provider had not always focused on continuous learning, innovation and improvement across the organisation and local system. They had not always encouraged creative ways of delivering equality of experience, outcome and quality of life for people or actively contributed to safe, effective practice and research.

The provider told us, ‘The organisation has reflected carefully on this and has implemented significant structural changes to strengthen assurance, governance and oversight’ and ‘The organisation is committed not only to addressing the specific issues identified at Pembroke House, but also to ensuring that the lessons learned strengthen governance, assurance and care quality across all The RNBT services.’

The management team had developed a quality improvement plan and was working to achieve improvements.