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 changed to Good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and staff were encouraged and supported to raise concerns, they felt confident they would be treated with compassion and understanding.

Staff told us they were updated about incidents and changes. Incidents and accidents were discussed in handovers, meetings and group supervisions to share learning. One staff member told us, “Our meetings and handovers keep us up to date with residents [people’s] needs and preferences.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The home worked with a number of professionals to ensure continuity of care within the home. The home had regular visits from the GP and made appropriate referrals to healthcare professionals.

Staff knew people and their risks well and told us how they worked with professionals to keep people safe. One staff member commented, “I work with GPs, nurses and the mental health team regularly. We work well together.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider reported concerns quickly and appropriately.

People using the service and their relatives told us they felt safe and were happy with their care. We were told, “Yes, I certainly feel safe, and there are always people here to help you.”

We spoke with staff about working with vulnerable people. One staff member told us, “I have had safeguarding training. If I suspected a resident [person] was being abused, I would tell my manager and contact the local authority.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In[care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS),which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that all DoLS applications and decisions had been managed appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

A risk management system was in place, and risk assessments were held in care plans. These provided staff with guidance on how to manage risk. For example, 1 person was at risk of falls. Guidance for staff included, using 2 staff to support the person, bed height being adjusted correctly and person being given explanations and reassurance during transfers. Another person was at risk of experiencing anxiety. Triggers to this anxiety were listed and calming measures gave staff ways to reassure the person. Staff we spoke with were aware of this guidance.

Where appropriate, mental capacity assessments were in place to safeguard people’s rights in relation to decisions about any risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home had fire safety equipment to meet standards, and staff had completed the relevant fire training and new fire doors had been fitted in the home. Water checks were regularly conducted and included legionella and water temperature testing. The provider had installed new fire doors in the home and had passed a fire inspection.

The home was clean and free from malodours and dementia friendly. The building was old. However, the provider had embarked on an extensive refurbishment and redecorating programme that we saw was ongoing.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

One staff member told us, “We have enough staff to support our residents [people] safely.”

People told us there were enough staff. One person said, “I think there’s enough staff. They have routines which really help me. When I ring the buzzer, they [staff] come swiftly enough.” Another person said, “They [staff] all work so hard.”

Throughout the inspection, we observed staff responded to people promptly and had time to interact with people whilst supporting them.

The provider had robust recruitment systems in place to ensure people were supported by well trained, experienced staff. Background checks were conducted to ensure staff were safe to work with vulnerable people.

Staff received supervision and records evidence staff training was up to date.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff wore personal protective equipment (PPE) during personal care. Staff understood the need to wear PPE and how to manage the risk of infection. Infection control policies were in place and up to date.

Cleaning schedules were in place, and people’s rooms were maintained to a high standard. Toilets and bathrooms were clean and regularly checked. One person told us, “The cleanliness is very good. I know everything needs a touch up but it’s an old building and that gives it such charm.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicine as prescribed. Staff had been trained to administer medicines, their competency to do so was regularly checked. Records confirmed any medicine errors were reported and investigated. One staff member told us, “I am trained to administer medicine, and my manager regularly checks me to ensure I am competent to do so.”

Medicine records were accurate and up to date and stock balances were correct. Drugs that required extra security were held securely and managed appropriately.

People’s medicines were regularly reviewed by the GP and regular audits monitored medicines to help the home manage medicines efficiently. Where people had ‘as required’ [PRN] medicines, protocols for there safe use were in place.