Pembroke Lodge

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 requires improvement. At this assessment the rating has remained 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 provider was previously in breach of legal regulations in relation to good governance and notifying CQC. Improvements were not found at this assessment, and the provider remained in breach of these 2 legal regulations.

At our last assessment we found breaches of the legal regulation in relation Duty of Candour. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There had been a recent change at provider level and the nominated individual and one of the deputy managers were open and honest with us about the service and the improvements needed in several areas. The nominated individual described their vision of improvements required and the direction they wanted the service to go in. However, there was a lack of action about how they would prioritise the improvements needed and timescales to undertake these to ensure people were assured of high-quality care and support.

The findings from this assessment evidenced the leadership had not provided assurance they had the skills, knowledge and experience to lead effectively. Management oversight of the service was not effective as they had not had time to develop and embed their roles and responsibilities.

Systems and processes in place did not support a consistent and clear oversight of the home and what improvements were needed.

Staff told us they had reported to management they needed more staff but this had not been acted upon. A staff member said, “Not enough staff most of theweekend. No cleaner and staff need to do cleaning. Rest of the time they have to feed residents and have to do cleaning in the kitchen”.

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

We received feedback from some staff who were concerned if they reported concerns these would not be treated confidentially.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff rotas were issued at very short notice which meant staff did not have a good work life balance. We were told rotas were often not received until the Friday to state what shifts were for the following week.

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.

Areas of concern identified and flagged to the provider at our last assessment and in our last report, persisted and this continued to impact on people’s safety.

The provider had not addressed concerns in relation to the environment placing people at harm. Audits were completed monthly by leaders but failed to identify gaps we found during our assessment. For example, sufficient risk and mental capacity assessments were not in place to mitigate risks to people, and people’s documentation contained conflicting information. The providers systems had not identified gaps and inconsistencies in records that might alert them to poor quality care provision.

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.

Services registered with the Care Quality Commission (CQC) are required to notify us of significant events and other incidents that happen in the service, without delay. This enables us to check appropriate action is taken to ensure people were safe. The provider had failed to notify CQC of reportable events including unexplained bruising and concerns of incidents between service users and the outcomes of Deprivation of Liberty applications.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We received mixed reviews from external bodies.The local authority was working closely with the service due to the concerns raised over the previous year. We requested feedback stating that communication and reporting incidents and accidents had been of a concern. More recent information from the local authority has noted some improvements in these areas.

We received some positive feedback from a health professional who stated the deputy manager worked effectively with multidisciplinary teams to ensure that care remained safe, proactive, and tailored to the individual. They expressed that they felt Pembroke Lodge had taken significant strides in improving the quality of care since the last inspection.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not refer to best practice such as supporting people living in an environment that supports their dementia symptoms.

Leaders failed to evidence effective quality assurance systems, and how these were operated to ensure continuous improvement in the service. There were no mechanisms in place to measure the impact of any changes made to ensure they had the desired impact.

They had not promoted a culture of learning, best practice, improvement and innovation. Nationally recognised monitoring tools such as dependency tools to determine staffing levels were not used.