Pembroke House

“At this assessment we found the quality of the service had deteriorated since we last inspected the service in 2021. We identified 5 breaches of the regulations relating to medicines management, staffing, management of risk, infection control, premises and equipment, person centred care and governance.”

“There had been a lack of clinical and management oversight of risks because systems had not been embedded to ensure risk assessments provided staff safe ways of working with people who had epilepsy, constipation, concerns around skin integrity and people on blood thinning medicines. Staff had not always received training and support to enable them to meet the assessed needs of people. The provider had failed to maintain equipment at the service which put people at risk of harm. People were not always enabled to receive care and support which met their preferences. Some people told us they preferred baths and despite asking for these they were not supported to have one. Care plans lacked guidance for staff. The systems to monitor the quality and safety of the service were not always effective. When shortfalls had been identified, action had not always been taken in a timely manner to make improvements and the shortfalls continued.”

“Staff were recruited safely. Staff treated people with kindness and knew people well. Staff spent time with people encouraging them to participate in activities and maintain important relationships with their families and friends. Staff told us they had received mixed support from the management team. Staff recognised that the provider had put in place a new management team and changes and improvements were starting to happen.”

“In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. We have also asked the provider for an action plan in response to the concerns found at this assessment.”