Pembroke House

Updated 25 September 2021

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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

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 two inspectors, a specialist nurse 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 or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The manager had been in post since June 2021, when the previous registered manager left the service. The manager had applied to be registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with 11 staff including the manager/clinical lead, deputy manager, a nurse, senior carer, four care staff, administrator, maintenance person and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also attended the daily departmental meeting.

We are improving how we hear people’s experience and views on services, when they have limited verbal communication. We have trained some CQC team members to use a symbol-based communication tool. We checked that this was a suitable communication method and that people were happy to use it with us. We did this by reading their care and communication plans and speaking to staff or relatives and the person themselves. In this report, we used this communication tool with two people to tell us their experience.

We reviewed a range of records. This included eight people’s care records and care notes. We looked at three staff recruitment files. We also saw a variety of records relating to the management of the service, such as health and safety, audits and staff meetings.

After the inspection

An expert by experience telephoned three people who lived at the service and nine relatives to gain feedback on the quality of the service provided.

We sought feedback from professionals who work with the service.

Updated 25 September 2021

About the service

Pembroke House is registered to provide people with nursing and residential care. It can accommodate up to 55 older people. At the time of this inspection there were 46 people living in the service. The service supports people with a wide variety of needs including those requiring minimal personal care to people with complex nursing needs. Accommodation is provided over three floors, with a number of lounges, dining rooms and a coffee shop.

The service provides care for former Royal Naval ratings, other ranks from the Royal Marines, their wives and widows and people who have had a connection with the Royal Navy. The Royal Naval Benevolent Trust (RNBT), a charitable non-profit making organisation, owns and manages the service.

People’s experience of using this service

People and their relatives told us that they experienced a service where staff were caring and respectful. Everyone said they would recommend the service to others. One person told us, “I would recommend people to come here; it is a pleasure. I would give them 11 out of 10”. Another person said, “This home is marvellous, and I could not have chosen better. The staff are excellent and nothing too much trouble. Staff are definitely well trained. My room is lovely, and my children are happy”.

People continued to be protected from the potential risk of abuse. Individual risks were identified and steps taken to reduce them. Staff had the guidance they needed to minimise harm to people whilst supporting independence.

Staffing levels were monitored so there were enough staff to meet people's needs. Recruitment practices were safe to ensure people were protected from the risk of unsuitable staff.

People continued to receive their medicines as prescribed by their GP. Medicines had been stored, administered, audited and reviewed regularly.

We were assured that the service could respond to COVID-19 and other infection outbreaks effectively.

Everyone said the service was well-led and that the manager and deputy managers were approachable. Systems to monitor the quality of the service provided, included gaining feedback from people who used the service.

The culture of the service was open and honest. Lessons had been learned when things had not gone the way that they should have gone. The management team were proactive in engaging staff in the service and as a result staff morale had improved. Staff felt well supported and listened to.

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

Rating at last inspection

The last rating for this service was Good (published 9 August 2018).

Why we inspected

This inspection was prompted by our data insight that assesses potential risks at services, concerns in relation to aspects of care provision and previous ratings. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. This enabled us to look at the concerns raised and review the previous ratings.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We found no evidence during this inspection that people were at risk of harm from these concerns. The overall rating for the service remains Good. This is based on the findings at this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pembroke House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.