Working at Pembroke Lodge

Safeguarding and medicines failures: 'The provider did not have their own record of safeguarding referrals.' 'Documentation in relation to people’s medicines were not up to date.'

Mixed morale with staff concerns about speaking up: 'Staff did not always feel they could speak up and their voice would be heard.' 'Some staff who were concerned if they reported concerns these would not be treated confidentially.'

Serious understaffing and unsafe levels: 'There were not sufficient numbers of staff.' 'Staffing levels were not sufficient to meet the needs of people.' Staff: 'No, there is not enough staff on some of the shifts.'

No registered manager in post and serious leadership failings: 'Pembroke Lodge did not have a registered manager in place.' 'The governance systems in place had not identified and addressed the widespread concerns found.'

Basic limited activities: 'Only 1 hour a day was allocated to activities. We observed people sleeping for much of the day with little interaction.'