Pembroke Lodge

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 requires improvement . At this assessment the rating has remained requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The provider was previously in breach of legal regulations in relation to safe care and treatment, and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations. ​

At our last assessment we made a recommendation to review the decoration of the premises in line with best practice guidance for people living with dementia and that the provider sought advice and support from a reputable source to record and maintain up to date records of people's capacity assessments, decision making and consent to receiving care and support. At this inspection there were no improvements. We therefore evidenced 2 new breaches of legal regulation in relation to premises and equipment and consent.

This service scored 46 (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’s care and treatment was effective. They did not check and discuss people’s health, care, wellbeing and communication needs with them.

The acting manager confirmed when people were being assessed to be supported by the service, management visited to meet with the person and/or their relatives to find out crucial information about their care and support needs. However, we did not see any of these pre-admission assessments which would inform the care planning. Care plans did not always contain full information such as reference to people’s social history or leisure/interests. There was limited information about supporting people with their emotions and behaviours, oral care and mobility needs.

Staff expressed concerns that people with nursing needs were being admitted into the service and the staff did not have the capacity or skills to always manage these safely. One member of staff said admittances sometimes took place on weekends and there was limited evidence to show how their needs could be met.

We reviewed a person’s care records and saw they did not have risk assessments or information about the use of a lap belt, continence, constipation, refusal of medicines, body maps, skin integrity, mobility, bed rails, nutrition, current wounds, and pressure risks. The person’s daily records stated they had a wound on their heel and leg and redness in an area of their body. However, this was not noted within the care plan or risk assessment about how staff should manage this.

There was no guidance on how staff would support someone who experienced and displayed distressed behaviours and how to manage the situation safely when the person experienced these to safeguard the person, staff and other people.

People’s records contained incomplete or incorrect assessments. This meant staff did not have clear guidance how to support people with their communication, support with continence, food and drink preferences and diabetes.

Care plans were reviewed on the provider’s electronic care planning system. There was no evidence of who was involved in reviewing the care plan to ensure it reflected people’s current needs and preferences. A relative said, “I am aware that [person] has a care plan. However, I have not seen anything in writing” and “I have not been invited to view or review [person’s] care plan.” We noted reviews had been undertaken. However, the quality of the reviews did not evidence they were effective in having oversight of completeness of people’s care plans and risk assessments being accurate and up to date.

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

People’s care plans did not always contain information that was relevant to them. Information was generic and appeared identical in other people’s care plans. There was no information about how to support and manage risks. For example, there was a section in people’s care plans stating, “Please consider my dietary preferences and any food allergies or intolerances when planning meals”. No information had been documented in relation to this. Another statement was, “Pay extra attention to areas that can cause concern such as pressure points”. There was no further information or guidance available for staff in relation to where these pressure points were.

Where external professionals such as occupational therapists had been consulted and assessments carried out, these were not reflected within people’s care plans. For example, an assessment was carried out on new equipment and the use of a Zimmer frame. However, this was not included within the care plan. An assessment had been completed about the having 2 care staff assisting the person to get in and out of bed. However, the information from this assessment had not been included in the care plan.

The provider did not always work well across teams and services to support people.

Staff discussed updates at handover meetings at the beginning and end of each shift. However, information within handovers were not always reflective of daily records. Staff meetings did not take place regularly but as part of the handover meetings.

The local authority was supporting the provider to identify improvements. An external health professional reported the provider was making improvements and felt they worked effectively with them.

The provider did not always support people to manage their health and well-being, so people could not always maximise their independence, choice and control.

Records did not always show how people were being supported to improve their health and well-being as any recommendations from healthcare professionals were not always reflected within people’s care plans and risk assessments.

There was limited activities that reflected people’s interests. A member of staff told us only 1 hour a day was allocated to activities. We observed people sleeping for much of the day with little interaction with care staff.

People were supported by visits from a regular GP. One staff member said, “We approach [deputy manager] who has a weekly phone call meeting with GP. We get information from any [hospital] discharge”.

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

Behavioural charts were not filled in to understand people’s support needs. There was incorrect information about wounds in people’s care plans. One person’s record stated throughout they had an open wound on their thigh. However, this had healed and therefore was no longer relevant. Body maps were not completed, and notes showed people had redness with no indication this was followed up with the GP.

People did not have wound care plans in place, repositioning, or guidance for staff to follow to meet clinical expectations. There was limited risk assessments and recording in place to monitor progress and recovery.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

The provider failed to gain consent from people, assess people’s capacity to consent where needed and to ensure any decisions made where a person was assessed as lacking capacity to consent, was made in the person’s best interest and was the least restrictive option for them.

People’s ability to consent was not documented. One person’s records stated, ‘Consent to care provision has not yet been given’. It also stated ‘No’ to ‘Care needs discussed with person or legitimate representative’. There were no supporting capacity assessments or best interests’ decisions in place. Documentation stated ‘Unable to give consent due to neurological condition. Consent has been gained from family/advocate to receive personal care, medicines’. There was no power of attorney or lasting power of attorney evidence to ensure the relative had legal authorisation to consent on the person’s behalf.

Another person’s care plan stated the same statement, ‘Unable to give consent gained from family/advocate for personal care, administration of medicines’. There were no capacity assessments in place, or information about how to gain consent. The person’s long-term care plan stated they were unable to consent and to follow mental capacity assessments. However, these were not in place.

There was no guidance in place for staff to understand people’s level of understanding, what they could and could not consent to, and how to obtain consent from individuals. Information about consent was generic not specific to people’s individual needs.

The service supported people from their neighbouring domiciliary care agency service throughout the day at the care home. We observed and also saw records that there had been incidents when a person, from this neighbouring service, attended the care home for day care had confronted residents of Pembroke Lodge resulting in incidents. People were not consulted on non-residents receiving day care in their home.