Updated 2 April 2025
Date of Assessment: 10 April to 23 April 2025. Pembroke Lodge is a care home providing accommodation and personal care to older people, some of whom were living with dementia. At this assessment there were 13 people using the service This was an unannounced, responsive assessment, prompted by emerging risk.
At the time of our assessment, Pembroke Lodge did not have a registered manager in place.
At our last assessment, the service was rated requires improvement and was in breach of 6 legal regulations in relation to safe care and treatment, good governance, fit and proper persons employed, notifying CQC of incidents or changes, and duty of candour.
At this assessment, we found continued breaches of legal regulations in relation to safe care and treatment and good governance and new breaches of legal regulations relating to person centred care, consent, staffing and premises and equipment and notifications.
People were not consistently receiving person-centred care that met their needs and kept them safe from avoidable harm. Care records and risk assessments were contradictory and not up to date to ensure staff received guidance to keep people safe and meet their needs. People were not always receiving the support they required to reduce their assessed risks such as pressure damage and falls. The shortfalls identified at this assessment did not demonstrate people were receiving a safe service at all times.
The home was not well-maintained throughout. The environment was tired and dated with areas of chipped paint and peeling wallpaper. Carpets had temporary repairs on them. The furniture was old and stained and the bed linen showed signs of wear.
Documentation in relation to people’s medicines were not up to date and there was limited guidance for staff to ensure medicines, including topical medicines, were administered and applied correctly.
There were not sufficient numbers of staff. There was no evidence of how staffing levels had been determined to ensure people’s assessed needs were safely met.
People had not always consented to their care, support and treatment. People’s records did not always evidence they had been involved in making decisions or relevant persons had been consulted.
The governance systems in place had not identified and addressed the widespread concerns found. The provider had made changes to their management structure just before the assessment visit. However, the concerns found evidenced the lack of leadership and minimal progress in improving the service since the last assessment in April 2023.
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