CQC report explained · a nursing home
What the CQC found at Pine Martin Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough skilled staff, safe recruitment, good risk management, safe medicines procedures and infection control arrangements. The Safe rating improved from Requires Improvement at the previous inspection.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found visible leadership, positive views from people, families and staff, clear staff roles and quality audits that were used to make improvements.
What inspectors found, May 2022
Pine Martin Grange was rated Good; inspectors found safe care and strong leadership, but there was no registered manager in post during the visit.
This was an unannounced inspection on 20 April 2022. One inspector and an Expert by Experience spoke with people living in the home, a relative, staff and the provider. They also checked care records, medicines records, staff recruitment files and management records.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found enough suitably recruited staff, safe medicines management, regular risk reviews and infection control arrangements that followed government guidance.
People, families and staff spoke positively about the management, teamwork and open culture. Audits were used to find and improve problems. The home was experiencing a COVID-19 outbreak during the visit, so some visiting restrictions were in place.
This was not a full review of all five CQC questions. The overall Good rating remained from the previous inspection, while the Safe rating improved from Requires Improvement to Good.
Enough staff
Inspectors found enough skilled and experienced staff to meet people's needs. Staff had also been recruited safely, including checks of references and DBS checks.
“People were supported by enough skilled and experienced staff to meet their care and support needs.” from the report
Safe medicines
Medicines were ordered, stored, given and disposed of safely. Staff who administered medicines had training and regular competency checks.
“People had their medicines ordered, stored, administered and disposed of safely.” from the report
Learning from incidents
The home used accidents and incidents to review practice and add further safeguards where needed.
“Accidents and other incidents had been used as an opportunity to reflect on practice and share learning.” from the report
Quality monitoring
The management team used audits to identify problems and drive improvements. Inspectors described the quality assurance processes as robust.
“Quality assurance processes were robust and used to drive improvements.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
No registered manager
needs fixingThere was no registered manager in post. The provider was managing the home, and a new manager was due to start in June 2022 and apply for registration.
“At the time of our inspection there was not a registered manager in post.” from the report
Night staff fire drills
needs fixingMost staff had taken part in fire drills, but night staff still needed to complete their practice at the time of the inspection.
“The provider told us night staff would complete fire drill practices before the end of the month.” from the report
- 01Has the manager who was due to start in June 2022 started, and have they applied for registration?
- 02Were the planned fire drills for night staff completed, and when was this checked?
- 03What visiting arrangements apply if there is a COVID-19 outbreak?
- 04How does the home check that staffing levels continue to meet people's needs?
- 05What changes were made after the dining experience audit found that drinks were not always being offered?
This was a focused inspection of Safe and Well-led; the other key question ratings were not inspected and the overall rating used ratings from the previous inspection. This explanation was written from the published report of 28 May 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, September 2018
Rated Good overall; inspectors found kind, effective care, but staffing levels meant the safe rating Requires Improvement.
Inspectors visited without notice on 24 July 2018 and continued the inspection on 25 July. They spoke with people living at the home, relatives, staff and health professionals. They reviewed care records, medicines, staff files, complaints, training and quality checks.
The home was rated Good overall. Caring, Effective, Responsive and Well-led were all rated Good. People were treated with kindness and dignity, their care was personalised, and staff supported them with food, activities and healthcare.
Safe was rated Requires Improvement because there were times when too few staff were available. This could leave people without support while other staff were giving personal care, completing paperwork or administering medicines. The provider agreed to increase staffing by 12 hours a day for three months and to review staffing using people's needs.
Kind and respectful care
People were treated with dignity and compassion. Inspectors saw staff being patient, gentle and encouraging, and people said staff knew them well.
“On both days of the inspection there was a calm and welcoming atmosphere in the home, punctuated with moments of singing and laughter.” from the report
Medicines managed safely
Medicines were securely stored, correctly recorded and given by trained staff whose competence had been checked.
“Medicines were managed safely, securely stored, correctly recorded and only administered by staff that were trained and assessed as competent to give medicines.” from the report
Personalised care
Care plans included people's needs, preferences, interests and history. Staff could access and update this information electronically while providing care.
“We found that the online care plans contained photos of people and information about the person, their family and history.” from the report
Activities and community links
People were offered varied activities, outings and opportunities to spend time with visitors. Activities were planned around people's interests and feedback.
“The activities coordinator told us that they plan and arrange a variety of activities in response to people's feedback, interests, hobbies and cultural beliefs.” from the report
Good quality monitoring
The management carried out regular checks covering areas such as care plans, medicines, staff files, the kitchen and equipment. Actions and progress were recorded.
“These systems were robust, effective, regularly monitored and ensured improvement actions were taken promptly.” from the report
Staffing levels
seriousThere were times when too few staff were available, including on the first floor. This meant people could be at risk while staff were helping others or completing other duties.
“This left people at potential risk of harm.” from the report
Mental capacity records
needs fixingSome capacity assessments and best-interest decisions were not recorded correctly. The management team said they were reviewing this paperwork.
“Capacity assessments and best interest decision paperwork had not always been completed correctly.” from the report
Complaint outcomes
minorThe home recorded complaints and the steps taken to respond, but the final outcomes were not always clearly documented.
“However, we did saw that outcomes were not always fully recorded.” from the report
Dementia-friendly signs
minorToilets and bathrooms on the dementia care floor were not clearly identified with visual signs. The home said it had ordered improved signage.
“However, signage was not clearly adapted to assist people living with dementia: toilets and bathrooms were not identified other than with small written signs.” from the report
No registered manager
needs fixingThe previous registered manager had left shortly before the inspection. The deputy manager was acting up while the home recruited a new manager and began a registration process.
“The service did not have a registered manager in post.” from the report
- 01How many extra staffing hours were added after the inspection, and are those hours still in place?
- 02How do you now calculate staffing levels according to each person's needs and dependency?
- 03Who is currently managing the home, and has the manager's registration process been completed?
- 04What changes were made to capacity assessments and best-interest decision records?
- 05How are complaint outcomes now recorded and shared with the person who raised the concern?
This was an inspection of the whole service, covering all five CQC questions, the care provided and the premises. This explanation was written from the published report of 1 September 2018 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 Martin Grange
2 rated inspections over 4 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018GoodSafe: Requires improvementWell-led: Good
- July 2017
Registered with the Care Quality Commission on 31 July 2017.
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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