CQC report explained · a residential care home
What the CQC found at Pine Lodge Care Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, August 2023
Rated Inadequate and placed in special measures; inspectors found serious risks in medicines, safeguarding, care planning and management.
This was the first inspection since the home was newly registered. It was unannounced and took place on 11 and 12 July 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines records, recruitment files and management records.
Inspectors found widespread problems. Medicines were not always given as prescribed, some safeguarding concerns were not reported, risks were not properly assessed, and food did not always meet people's health needs. Staff recruitment, training and supervision were also not reliable. Records and quality checks were incomplete or ineffective.
Staff were kind and there were enough staff to respond to people's requests. However, people were not always treated with dignity, involved in decisions, supported with meaningful activities or given information in ways they could understand. The home was rated Inadequate overall, with Inadequate ratings for Safe, Effective and Well-led, and Requires Improvement for Caring and Responsive.
Kind staff
Inspectors saw staff speaking to people respectfully and treating them with kindness and compassion. Relatives also said staff were polite, kind and welcoming.
“We observed staff treating people with kindness and compassion and respecting their wishes and preferences.” from the report
Enough staff available
Inspectors found there were enough staff to meet people's needs and saw staff respond promptly when people asked for help.
“There were enough staff to meet people's needs. We observed staff responding promptly to people's requests for assistance.” from the report
Visitors allowed
There were no restrictions on people receiving visitors, and inspectors saw people spending time with their relatives.
“There were no restrictions on people receiving visitors. A relative told us, "I am not restricted to visiting times".” from the report
Complaints process
People and relatives felt able to raise concerns. Complaints received had been investigated and responses had been sent.
“A process was in place to receive, investigate and respond to complaints.” from the report
Infection prevention
Inspectors were assured that the home had arrangements to prevent and manage infection risks, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines not safely managed
seriousSome people did not receive medicines as prescribed. Records had gaps, medicines were sometimes given at the wrong time, and four people went without a medicine for between four and 14 days.
“Two people had not received their insulin as prescribed in May and June 2023.” from the report
Safeguarding and risk failures
seriousThree incidents, including a serious injury from a fall and a wound, were not reported to the local authority safeguarding team. Risk guidance for diabetes, catheters, pressure ulcers and emergencies was also incomplete.
“Three incidents had not been reported to the local authority safeguarding team for consideration.” from the report
Food did not always meet needs
seriousPeople at risk of losing weight did not have food planned in line with relevant guidance. People with diabetes were not always offered low-sugar food.
“People living with diabetes were not offered a diet low in sugar.” from the report
Consent and privacy
seriousPeople were not always involved in decisions about shared bedrooms, photographs or CCTV. The home did not consistently follow the required consent and best-interest processes.
“People had not been consulted about the installation of CCTV in communal areas of the service.” from the report
Weak management oversight
seriousAudits had not identified or corrected important problems. Care plans, medicine records and other records were not always accurate, complete or kept up to date.
“The provider and registered manager's oversight of the service was inadequate.” from the report
- 01What has been done to ensure every person receives their medicines, including insulin, at the prescribed time and dose?
- 02How are safeguarding incidents now reported, investigated and used to prevent further harm?
- 03How many staff have completed all required training, medicines competency checks and regular supervision?
- 04What changes have been made to care plans, risk assessments and records so staff have accurate guidance about each person's needs?
- 05How are people now being consulted about CCTV, shared bedrooms, end of life wishes and other decisions affecting their privacy and choice?
This was an unannounced inspection of the whole care home and all five key questions, including care, premises, records, medicines, staff files and management systems. This explanation was written from the published report of 24 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Pine Lodge Care Home
3 rated inspections over 7 years: the service has slipped, from Requires improvement to Inadequate.
- August 2023Inadequatecurrent ratingSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2020Inspected but not ratedSafe: Inspected but not rated
- August 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022
Registered with the Care Quality Commission on 6 January 2022.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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39 live-in carers within about an hour of Kent
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 33 can care for a couple. 12 years' experience on average.
“Always on time and with a lovely smile for my mum. Theresa is kind and sensitive to my mum's needs.”
“Irene was a very kind and empathetic carer who knew just the right words to say to put a smile on my face.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.