CQC Report - Building on our ‘Good’ Care Home Rating
CQC conducted an inspection on 9th August 2021 and concluded the Home remained 'Good' in safety and well led. This means the home retains its overall inspection rating of 'Good', following the 'Good' inspection of all of the Care Quality Commissions Key Lines of Enquiry (KLOE) in 2018.
Regulation 12 Warning Notice
Following a Care Quality Commission (CQC) inspection in mid-June, Pembroke House has been issued a Regulation 12 Warning Notice in relation to medicines management. Inspectors identified concerns, primarily relating to how medicines were ordered, stored, administered and governed at Pembroke House.
We accept these findings and the safety of every person who lives at Pembroke House is our most important responsibility, and we acknowledge that medicines management was not consistently meeting the standard required.
Action Already Taken
The RNBT had already identified concerns at Pembroke House prior to this inspection and before CQC’s visit we took action to:
- Strengthen clinical leadership and bring in an interim management team
- Commission independent quality reviews
- Introduce a new quality monitoring and governance framework
- Bring in additional operational and clinical resources to support the service
- Appoint a new permanent Home Manager to take Pembroke House forward
CQC inspectors recognised these steps, acknowledging that the new Home Manager and current interim management were aware of and tackling many of these inherited issues and that significant governance improvements were already underway.
What We Are Doing Now
Our Chief Executive and Senior Leadership Team are working directly alongside the team at Pembroke House, providing on-site support as we drive improvements across the service. We are working openly and transparently with CQC throughout this process, and we are committed to demonstrating sustained, meaningful improvement, not just in the areas covered by the Notice, but across everything we do at Pembroke House.
We are focused on meeting the CQCs compliance deadline of 31 August 2026 with these improvements to the service.
We are committed to ensuring that the care provided at Pembroke House is consistently safe, compassionate and of the highest quality.