Archived: Pembroke House

Updated 16 December 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by four inspectors over the two days of inspection, a specialist advisor with expertise in this type of service and an expert by experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Pembroke House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pembroke House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

Both inspection visits were unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with ten people who lived at Pembroke House and three relatives about their experience of the care provided. We spoke with 26 staff members in total, including the registered manager, clinical lead, dementia and residential care managers, activity lead, chef and regional directors and 18 members the care and nursing team. We spent time observing the care people received. We reviewed a range of records. This included thirteen people's care records and multiple medication records. We looked at five staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including accidents and incidents, complaints and policies and procedures were reviewed. We looked at training data and quality assurance records

Updated 16 December 2022

About the service

Pembroke House is a residential care home providing personal and nursing care to up to 100 people. The service is purpose-built and provides accommodation and facilities over five floors. The third floor provides care and support to people who are living with dementia, this area is called The Lodge. The other areas of the home provide care for people requiring 'assisted living'. Some people lead a mainly independent life and use the home's facilities to support their lifestyle. At the time of our inspection, there were 58 people living at Pembroke House.

People’s experience of using this service and what we found

People felt safe living at Pembroke House and staff were aware of how to identify and report concerns about people’s care. Risks to people’s safety and well-being were identified and measures implemented to reduce risks. Robust infection prevention and control processes were in place to minimise the risk of cross infection. People received their medicines in line with their prescriptions and medicines were stored safely. The management team were monitoring this process closely to ensure previous concerns were being addressed effectively.

There were sufficient staff deployed to meet people’s needs. The high use of agency staff was being addressed and the skills of agency staff were reviewed to ensure those employed were able to meet people’s needs. Safe recruitment processes were in place. Staff received training and induction to support them in their roles.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff supported people in a personalised way and respected people’s choices and decisions. People told us staff were kind and respected their dignity and privacy. People told us they enjoyed the food and had a range of options to choose from. People had access to health care professionals and staff had guidance regarding specific health conditions to refer to.

Staff knew people’s needs and preferences well and were informed of any changes to people’s care. Staff understood people’s individual communication needs. People were involved in developing the activities programme to ensure activities were relevant to them. People were encouraged to continue using facilities available in the town centre. There were regular trips to places of interest and entertainers performed at Pembroke House frequently. People were able to receive visitors when they wished.

People, relatives and staff told us they felt the home was managed well and there was a positive and welcoming atmosphere. Staff felt supported by the leadership team and requests for changes to systems were listened to. Quality assurance audits were completed regularly and a service improvement plan was used to monitor actions arising from any shortfalls identified. The provider was in the process of rolling out their dementia care strategy to further develop and promote people living well with dementia and being at the centre of their own care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

Pembroke House is run by two companies: WR Signature Operations Limited and Signature Senior Lifestyle Operations Ltd. These two companies have a dual registration and are jointly responsible for the services at the home. The last rating for the service under WR Signature Operations Limited was good (published 09 August 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service. Following our first day of inspection we received information of concern in relation to people’s safe care. A decision was made to return to the service at night to examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.