Pembroke Care (Reading) was rated Requires Improvement overall following a focused inspection prompted by a safeguarding concern, with breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) identified. Key failures included unsafe medicines management, absent PRN protocols and risk assessments, an ineffective governance framework, and an inadequate post-abuse investigation, though staffing, recruitment, infection control and personalised care planning were found to be good.
Concerns (10)
criticalMedication management: “There were not protocols in people's care records to provide instruction to staff on how to assess when people needed these medicines and how to administer them safely.”
critical
Medication management
: “The providers medicines audits were not effective in identifying errors and discrepancies in people's medicines administration records (MARs).”
criticalCare planning: “One person who was at risk of falls lived in a house which also had a swimming pool in the grounds. There was no risk assessment in the person's care plan.”
criticalGovernance: “There was no overall action plan. This meant the provider did not maintain a sufficiently detailed oversight of the service and any improvements which needed to be made.”
criticalSafeguarding: “Following an incident of abuse the provider had failed to conduct a sufficiently robust investigation to prevent a recurrence and safeguard people from harm.”
moderateStaff training: “The provider's staff training matrix did not evidence if staff were up to date with their training or when refresher training was due.”
moderateIncident learning: “There was a lack of evidence to demonstrate the provider analysed accidents and incidents to identify trends and themes to prevent recurrences.”
moderateConsent / capacity: “There was a lack of evidence to show the provider had recorded people's consent to receiving care and support. None of the care plans we reviewed contained consent forms signed by people.”
moderateRecord keeping: “The management team completed staff medicines competency assessments to identify areas for improvement. However, they told us they had not kept records of the assessments.”
minorPerson-centred care: “The provider had not sought any feedback from people about their views on the quality and suitability of care and support delivered.”
Strengths
· People were protected from the risk of abuse and staff could clearly describe signs of abuse and reporting procedures.
· Sufficient staffing levels providing continuity of care from familiar staff.
· Robust recruitment process including DBS checks, references and employment history verification.
· People were protected from infection risk with trained staff and adequate PPE.
· Care plans were personalised, regularly reviewed and included evidence-based assessment tools.
Quality-Statement breakdown (15)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: How the provider understands and acts on the duty of candourGood