CQC Rating
Following a Care Quality Commission (CQC) inspection in June 2026, Pembroke House has been rated as Requires Improvement. We acknowledge this rating and take it seriously.
It is important to understand the context in which the inspection took place. The visit occurred during a period of significant change at Pembroke House, in which The RNBT had already identified concerns, commissioned independent reviews, and was actively implementing structural and leadership changes. The rating is a snapshot of the home at that moment, and a significant amount of improvement work was already underway when the CQC visited the home.
Alongside the areas requiring improvement, the CQC found genuine strengths. Residents consistently described staff as kind, caring and compassionate, and this was borne out in what inspectors observed throughout their visit. Safeguarding, wound management, multidisciplinary teamworking and community links were all recognised positively.
We are committed to addressing every area identified in the report and demonstrating a standard of care at Pembroke House that our residents deserve. You can read more about our investment in Pembroke House and our wider commitment to both our care homes here.
Regulation 12 Warning Notice
Alongside the inspection report, CQC has issued Pembroke House with a Regulation 12 Warning Notice in relation to medicines management. The primary concerns identified relate to how medicines were ordered, stored and governed, not specifically to individual residents failing to receive their medication. Problems with our previous pharmacy supplier had resulted in significantly more medication being held on site than was necessary or appropriate. We have addressed this directly by changing pharmacy supplier and strengthening our internal auditing processes.
A Regulation 12 Warning Notice is not an enforcement action and does not place the home in special measures. It is a formal prompt from the CQC to rectify specific processes within a defined deadline. We are working to meet that deadline and are in ongoing contact with the CQC throughout.
Action Already Taken
The RNBT had already identified concerns at Pembroke House before the CQC inspection took place. Before inspectors arrived, we had acted to:
- Strengthen clinical leadership and bring in an interim management team
- Appoint a new permanent Home Manager to lead Pembroke House forward
- Commission independent quality reviews
- Introduce a new quality monitoring and governance framework
- Bring in additional operational and clinical resources to support the service
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. This work spans medicines governance, care planning, risk management, staffing and training, and the governance systems that underpin safe and effective care. RNBT Trustees are also undertaking regular visits to speak directly with residents, relatives and staff to observe the lived experience in the Home. The leadership team now in place at Pembroke House includes the Home Manager who holds overall responsibility and is the lead clinician, a Dementia Services Manager with specific responsibility for dementia care, an Operations Manager leading on the environment, housekeeping and catering, and an Interim Care Director overseeing governance, quality and the wider improvement programme. An independent pharmacy audit has been completed and was positive, with a small number of further actions identified and being addressed. Peer medication audits are being undertaken by the senior team from our second care home, Admiral Jellicoe House. Medication management continues to be monitored closely to ensure improved standards are consistently maintained.
We are working openly and transparently with the CQC throughout and are committed to demonstrating sustained, meaningful improvement, not just in the areas covered by the Warning Notice, but across everything we do at Pembroke House.
We are committed to ensuring that the care provided at Pembroke House is consistently safe, compassionate and of the highest quality.
Pembroke House has an Overall Rating of Requires Improvement, as per the latest CQC report.
