CQC report explained · a nursing home
What the CQC found at Pine Tree Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2022
Pine Tree Court Care Home is rated Requires Improvement; inspectors found risks in care planning and recruitment, although people felt safe and staff were caring.
The home provides personal and nursing care for older people living with dementia. At the inspection, 18 people were living there, although the home can support up to 40 people.
This was an unannounced focused inspection. Two inspectors and an Expert by Experience spoke with people, relatives and staff, observed care, and reviewed care, medicine, recruitment and management records. They looked only at Safe and Well-led. Both were rated Requires Improvement.
Inspectors found that some care plans did not give staff clear, current guidance about people's risks. Records did not always show that planned care had been given. Recruitment checks were also incomplete, and COVID-19 guidance had not always been followed, although the management acted immediately on some concerns.
The overall rating changed from Good at the previous inspection to Requires Improvement. The report says the provider must send an action plan, while CQC continues to monitor progress.
Enough staff
People, relatives and staff said there were enough staff to meet people's needs. Inspectors also found enough skilled and suitable staff deployed.
“There were enough skilled and suitable staff deployed to meet people's needs.” from the report
Medicines
Medicines were administered by trained staff whose knowledge and practice were checked. Clear guidance was in place for medicines given covertly or when people were anxious.
“People received support with their medicines from suitably trained staff.” from the report
Individual care
Inspectors saw examples of care tailored to people living with dementia. Staff and management were motivated to provide compassionate care.
“Staff and management were motivated to provide compassionate and individualised care to people living with dementia.” from the report
Learning from incidents
The management had systems for reviewing incidents and accidents. Inspectors found that lessons and recommendations had been put into practice.
“Lessons learnt and recommendations had been implemented to ensure the risk of these incidents reoccurring was reduced.” from the report
Care plans and risk records
seriousSome care plans were not updated when people's needs changed or after incidents. Records did not always show that planned care, including ulcer care, had been provided.
“People's care plans had not always been updated to provide staff with clear and current guidance on how to meet people's needs.” from the report
Recruitment checks
seriousThe required pre-employment checks were not always completed. Some records lacked references from previous social care employers and contained gaps in employment histories.
“Safe recruitment practices had not always been followed. This placed people at risk of harm.” from the report
Leadership and oversight
needs fixingThere was no registered manager in post. The provider's monitoring had not identified the recruitment problems, and records did not always show how risks were being managed during improvement work.
“At the time of our inspection there was not a registered manager in post.” from the report
COVID-19 guidance
needs fixingThe home had not always followed government guidance for testing people admitted from the community. Management took immediate action after inspectors raised this.
“The service had not always followed government COVID-19 guidance.” from the report
- 01Which residents' care plans have been updated since the inspection, and how are staff told about any risks while updates are being completed?
- 02How do you now record care for people with ulcers or other skin damage, including care provided by healthcare professionals or agency staff?
- 03Have all required employment checks and references been completed for current staff, and how are gaps in employment histories reviewed?
- 04Has a registered manager been appointed, and who is currently responsible for checking that audit actions are completed?
- 05What was the outcome of the trial involving remote nursing support at night, and how are you checking that it remains safe for residents?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 22 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, December 2020
Inspected but not rated; inspectors found good infection control, with some Covid-19 risk assessments needing more detail.
The inspection took place on 24 November 2020 and was announced. It was part of a CQC thematic review during the coronavirus pandemic, focusing on infection prevention and control in care homes.
Inspectors found that the home was following safe infection control procedures. Visitors had temperature checks, handwashing facilities and sanitiser. Staff used personal protective equipment, changed uniforms and cleaned their hands regularly.
The home had testing, cleaning, monitoring and outbreak plans in place. It was also arranging safer visits for families. Inspectors recommended adding more detail to some staff and resident Covid-19 risk assessments.
The service was inspected but not rated. This means the report does not give a Good, Requires Improvement or Inadequate rating, and it does not provide a full assessment of all areas of care.
PPE and staff hygiene
Staff were trained in infection control and were observed using PPE, changing it when needed and regularly sanitising their hands.
“We were assured that the provider was using PPE effectively and safely.” from the report
Testing and monitoring
The home regularly checked residents' wellbeing and had a testing programme for residents and staff.
“Staff regularly monitored the well-being of people such as twice daily temperature checks to identify any soft signs of the virus.” from the report
Outbreak planning
Plans were in place to separate people and organise care if someone showed symptoms, tested positive or there was an outbreak.
“Plans were in place to zone the home if people were admitted into the home or people showed signs of the virus, tested positive or if there was an outbreak of Covid-19 in the home.” from the report
Staff risk assessments
needs fixingInspectors recommended that staff risk assessments should cover Covid-19 risks for staff from BAME communities and risks linked to agency staff.
“We have recommended that staff risk assessments include Covid-19 risks relating to staff from BAME communities and be extended to include risks relating to the use of agency staff.” from the report
Resident risk assessments
needs fixingInspectors recommended adding risks for people from BAME communities, people who may refuse a Covid-19 test and people who walk with purpose.
“We have recommended that the provider extends the risk assessments to include risks relating to people from BAME communities, those people who may refuse to take a Covid-19 test and those people who walk with purpose and are at risk of transmitting or contracting the virus.” from the report
- 01Have you completed the recommended Covid-19 risk assessments for staff from BAME communities and agency staff?
- 02Have resident risk assessments been updated for people who may refuse Covid-19 testing or who walk with purpose?
- 03What infection control and outbreak arrangements are in place now?
- 04How are family visits arranged and carried out now?
- 05Can you show how the home monitors the effectiveness of its infection prevention and control arrangements?
This was an announced thematic inspection focused on infection prevention and control under Safe; the other four questions and a full overall rating were not assessed. This explanation was written from the published report of 18 December 2020 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 Tree Court Care Home
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- July 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- May 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- September 2016Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementstayed Requires improvementEffective: Requires improvement
- April 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 21 April 2011.
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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