Pembroke Lodge

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 requires improvement. At this assessment the rating has remained 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 provider was previously in breach of legal regulations in relation to safe care and treatment, good governance and fit and proper persons employed. Improvements were not found at this assessment, and the provider remained in breach of these regulations. ​

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Records and audits did not identify how lessons were learned and used to drive improvement in the service. While accidents and incidents were recorded, the provider did not have an effective system for investigating incidents such as unexplained bruising or skin tears. Examples in people’s daily notes, had not been recorded on the incidents and accidents to investigate and take actions. No reflective processes were in place for staff after incidents had occurred to learn lessons. As a result, people remained at risk of harm.

The provider had not made the necessary improvements in the service since our last assessment, to ensure people using the service received safe care at all times. This does not demonstrate a learning culture within the service at provider and management level. We were not assured the provider had robust systems to independently identify risks and poor outcomes and address them.

The provider had not always ensured safe systems to ensure continuity of care. People’s care records contained inaccurate or missing information such as their care and support needs. Therefore, if people required hospital admission, inaccurate information could compromise people’s safety. Care plans and risk assessments had not been kept up to date to show people’s current needs. For example, a person’s care plan and risk assessments had conflicting information about the support they required with their continence needs. Inaccurate information could be passed to other healthcare staff which could impact upon people’s treatment and support.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety and ensure avoidable harm and neglect was reduced. The provider did not always share concerns quickly and appropriately.

The provider did not have their own record of safeguarding referrals. The provider told us they depended on the local authority system. They did not have access to these at the time of the inspection. Therefore, there was no evidence safeguarding referrals were being made when required and we could not assess how the provider tracked, investigated and identified themes and learning actions from safeguarding outcomes.

Care notes documented bruising and skin tears people had sustained. It was unclear whether these had been reported to the local safeguarding team. CQC had not been updated about these incidents.

People who could communicate verbally confirmed that they felt safe living at Pembroke Lodge.

Staff confirmed they had received safeguarding training and confirmed they knew how to raise safeguarding concerns. However, they did not always receive feedback of the outcome of these.

The provider did not always work well with people to understand and manage risks. There was no evidence people were involved in care planning and identifying risks and how these would be managed.

People’s documentation did not contain evidence of initial needs assessments to inform care plans and risk assessments. There was no evidence provided to show people and/or their relatives were consulted in their ongoing care. Two people’s relatives told us they had not been given the opportunity to review their family member’s care plan with staff to ensure it reflected their family member’s needs and preferences and to suggest changes.

Staff did not always have the correct information in place to ensure they met people’s needs safely and consistently, and enabled people to do the things that mattered to them.

People’s documentation contained numerous examples of how risks had not been adequately assessed, mitigated and monitored. For example, risks relating to people’s mobility, medicines and continence. People’s care records had conflicting information. For example, there was incorrect mobility information in a person’s care plan. It stated they required full assistance with all care tasks. In another section of the care plan, it stated they could wash and mobilise themselves.

Where people needed support to manage distressed behaviours, behaviour forms were used. However, there was no guidance on these forms to guide staff about what may trigger a person to become distressed and how to manage this to reduce the distress and further escalation.

There was no written information held in the kitchen about people’s dietary needs. This included those who needed food at a different consistency to ensure they did not experience choking. We asked about records for people losing weight, or at risk of losing weight and there were no records kept in the kitchen. One person’s care plan and risk assessment had identified risk of malnutrition and requiring additional calories and potentially referral to a dietitian or GP. The daily records did not evidence the person’s nutrition was being supplemented. Other people had diabetes which was controlled by diet but there were no records kept ensuring a safe diet was provided.

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.

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 bed linen showed signs of wear. The provider has informed us that some carpets have been replaced since the inspection took place.

Records of health and safety checks had been completed and identified actions required relating to the carpets and other equipment such as cracked basins and worn chairs. However, they did not evidence how these would be prioritised and there was no assurance they would be completed in a reasonable timeframe.

An external fire inspection had taken place in June 2023, some of the actions were not evidenced as being completed. The provider informed us staff discussed evacuation plans at team meetings however, there were no records of this. One person who was not mobile stated they were unaware of any evacuation procedure should there ever be a fire at Pembroke Lodge. Personal Emergency Evacuation Plans (PEEPs) contained incorrect room numbers which would not allow emergency services or fire services to allocate the correct room where needed. This placed people at risk of living in an unsafe environment. After the assessment the provider assured us, they had reviewed this and ensured identification of people’s rooms had been undertaken.

Health and safety checks including fire, moving and handling equipment were undertaken to reduce risks to people.

The home had a very pleasant roomy garden for people to enjoy.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

At the time of the inspection, we asked but were told the service did not have a dependency tool in place to determine appropriate levels of staff. Since the inspection the provider has implemented a data-led dependency tool to determine the number of care hours each person is assessed as requiring. Staffing levels were not sufficient to meet the needs of people. People in the service had high dependency needs and staff were therefore engaged in undertaking tasks with little time to interact with people in a meaningful way. People had unwitnessed falls which suggested staff resources were not sufficient to supervise them and keep them safe.

The same staff working at Pembroke Lodge also worked in the provider’s other service which provided domiciliary care support. People from this service were supported at Pembroke Lodge during the day by the same level of staff. There was no analysis of how this impacted upon staff being able to provide a safe level of care to increased numbers of people during the day and to provide overnight cover.

Staff did not feel there were enough staff to provide safe and effective care. Comments included, “No, there is not enough staff on some of the shifts. It is affecting the staff and also the residents” and “Not at the moment as most residents require 2 care staff”. We also heard concerns about the amount of cleaning and laundry care staff were required to undertake alongside their caring responsibilities. This decreased the amount of time staff could support residents.

A relative expressed concern about management of the service at weekends. They commented, “There are no deputy managers on site during weekends. Only one of the three deputy managers is ‘on call’ for residents’ health needs overnight and at weekends. This means the same deputy manager is always ‘on call’ 365 days, 24 hours a day. Not only is this not fair on the individual, but it also presents a significant risk to the residents if that person becomes unavailable. I am told that the other two deputy managers are ‘on call’ at weekends for infrastructure issues e.g. problems with utilities such as water/electricity. I feel a form of management presence at weekends is necessary to ensure best practices are implemented 7 days a week”.

Staff were not always safely recruited. A member of staff did not have a DBS clearance until 3 months after they started. The management stated the care staff did not work on their own, but they did not have a risk assessment in place for this.Staff files did not contain all required legal information as required by Regulation 19 of the Health and Social Care Act (Regulated Activities) regulations. For example, there was incomplete recruitment records, including interview records, kept about what information was sought and provided as part of staff interviews.

Staff informed us they had supervision meetings with managers. Supervision records did not document actions required.

Staff confirmed they felt they had received sufficient training in line with their responsibilities.

The provider did not always effectively manage the risk of infection.

Although infection prevention and control audits took place, the service was not in a good state of repair which made effective cleaning challenging. Chipped paintwork, damaged flooring, furniture and hand basins posed the risk of cleaning not being effective

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

Medicines were not always documented in peoples care plans, were not up to date, and did not inform staff of where to apply creams. Information such as pain and people’s ability to communicate pain was not documented. Transdermal patches (a medicated adhesive patch applied to the skin to deliver medication directly into the bloodstream) were seen as being used in peoples care notes, however there was no mention of this within their care plan. There was no guidance for staff if the patch came off, how to manage the patch when undertaking personal care, or when the patch needed to be applied or renewed.