CQC report explained · a residential care home
What the CQC found at Pine Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staff understood people's risks and medicines were managed safely. However, some risk assessments were unclear or out of date, and staffing shortages led to regular use of agency staff.
- Effective?
- Requires improvement
- Staff were trained, supervised and supported people to access health care. Mental capacity assessments and decisions about restrictions did not consistently follow the law.
- Caring?
- Requires improvement
- Staff were knowledgeable and some relatives praised their care. However, records used undignified language, personal care was not always provided well, and preferred routines were not fully recorded.
- Responsive?
- Requires improvement
- People could keep in touch with relatives and staff supported their communication needs. However, staffing shortages limited outings and activities, and care plans did not always reflect changes in people's needs.
- Well-led?
- Requires improvement
- The manager was described as approachable and open. However, audits had not identified important gaps in care records, and the provider had not shown that feedback about activities had led to action.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found caring staff and safe medicines support, but important gaps in consent, records, staffing and oversight.
This was the first inspection of the newly registered service. It was unannounced and took place on 08 and 09 June 2022. Inspectors reviewed care records, risk assessments, staff files, training records and management audits. They also spoke with relatives, care staff and managers.
The home protected people from abuse and avoidable harm, supported medicines safely and helped people access health care. Staff were described as kind and trained. However, staffing shortages meant people could miss outings and activities. Some care plans and risk assessments were out of date or lacked important guidance.
The home was not always following the law when making decisions for people who may lack mental capacity. Its checks had not found these problems. The overall rating and all five question ratings were Requires Improvement, meaning the inspectors found inconsistent care and limited assurance about safety.
Medicines
Medicines were administered, stored, ordered and disposed of safely. Records and audits were used to check that procedures were followed.
“People received support with their medicines safely and in the way they preferred.” from the report
Protection from abuse
People were protected from abuse and avoidable harm. Staff had safeguarding training, and investigations and lessons learned were recorded.
“People using the service were protected from the risk of abuse.” from the report
Staff training
New staff completed induction and shadowing. Staff had mandatory training, supervision and access to further development.
“Each new member of staff was required to complete induction training that included working alongside (shadowing) experienced staff before they started supporting people with their care.” from the report
Health care support
People were supported to attend health appointments and received timely help when they became unwell.
“The staff took [Person] to see their GP, rather than leave it until they came home.” from the report
Approachable management
Relatives and staff said the manager was approachable. The manager responded to some feedback and acted immediately on some inspection findings.
“The registered manager promoted an open and welcoming culture.” from the report
Risk records
seriousSome risk assessments gave unclear or conflicting instructions. Records about skin damage and emotional distress were not always complete or up to date.
“One person's support plan had contradictory guidance on the steps to follow in response to the person experiencing an epileptic seizure.” from the report
Consent and choice
seriousMental capacity assessments did not show how people had been involved. Restrictions on some food and drinks were not supported by the required decision-making records.
“The provider had failed to ensure the principles of the MCA were consistently followed to ensure people's rights were protected.” from the report
Staffing and activities
needs fixingVacancies and staff turnover meant the home regularly used agency staff. Relatives said people were sometimes unable to go out, follow interests or receive planned one-to-one support.
“Not having a full team of regular care staff meant people were not always supported to follow their hobbies and interests.” from the report
Care records
needs fixingSome plans had not been updated when people's needs changed. Important information about preferred routines was missing, which could lead to inconsistent support.
“We found support plans had not always been updated to reflect changes since the previous respite stay.” from the report
Personal care and dignity
needs fixingA relative reported poor personal hygiene for one person. One care record also used language that did not promote dignity.
“People not always being supported to meet their personal care needs, placed them at risk of their dignity not being promoted.” from the report
Governance
seriousThe home's audits had not identified important gaps in records or shown effective action after feedback about reduced activities. This was a breach of the good governance regulation.
“The provider had failed to ensure effective governance systems were in place to bring about identified change in a timely manner and promote good quality outcomes for people.” from the report
- 01How many permanent care staff are now in post, and how will you guarantee planned one-to-one support and outings?
- 02How do you record and review mental capacity assessments and best-interest decisions, including decisions about food and drinks?
- 03How often are care plans and risk assessments reviewed after a person's needs change?
- 04What action has been taken to improve activities and opportunities for people to go out?
- 05How have you fixed the gaps in care records identified by the inspection, including plans for seizures, skin damage and emotional distress?
This was a first, planned inspection of the newly registered care home and covered all five quality questions, including infection prevention and control. This explanation was written from the published report of 29 July 2022 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.
What inspectors found, February 2022
Inspected but not rated; inspectors were assured about infection control, visiting arrangements and COVID-19 precautions.
This was a targeted, announced inspection on 25 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19.
The home supported short-term breaks and respite care for up to 12 people. There were two people staying there at the time. Inspectors found visitors had to provide evidence of testing and vaccination or medical exemption, and staff used protective equipment safely.
Inspectors were assured that the home admitted people safely, managed infection risks, used testing and kept its infection control policy up to date. The service was inspected but not rated, so this report does not give an overall quality rating.
Infection control
Inspectors found that the home had suitable measures to reduce the spread of infection. This included PPE, handwashing information, cleaning schedules and a regularly reviewed COVID-19 risk assessment.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safe visiting
Visitors had to provide evidence of a negative LFD test and vaccination, unless medically exempt. They could visit in suitable areas or take their relative out of the home.
“Visitors were encouraged to visit within the person's bedroom, or large communal room or take their relative out of the home.” from the report
Cleaning arrangements
Cleaning records were designed for each area, and bedrooms were cleaned after each person's discharge before the next occupant arrived.
“Bedrooms were thoroughly cleaned upon people's discharge and signage displayed to show the room had been cleaned and had been prepared for the next occupant.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you manage staffing pressures if COVID-19 affected the team during my relative's stay?
- 02What testing, vaccination or medical exemption evidence would my relative and visiting family members need to provide?
- 03How would you support my relative if they were unable to take part in routine testing because of the invasive nature of the test?
- 04How would family visits be arranged, and where could we spend time with our relative?
- 05How would you monitor my relative's health and welfare during a short-term respite stay?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated in this report. This explanation was written from the published report of 4 February 2022 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
Each visit the CQC has published, newest first, back to the day the home was registered.
- July 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2021
Registered with the Care Quality Commission on 1 April 2021.
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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