CQC report explained · a residential care home
What the CQC found at Pinehurst Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. The home had enough trained staff, improved recruitment checks, safe medicine systems, appropriate risk assessments and effective infection prevention measures.
- Effective?
- Good
- This area was not looked at during this focused inspection. The rating from the previous comprehensive inspection was used in calculating the overall rating.
- Caring?
- Good
- This area was not looked at during this focused inspection. The rating from the previous comprehensive inspection was used in calculating the overall rating.
- Responsive?
- Good
- This area was not looked at during this focused inspection. The rating from the previous comprehensive inspection was used in calculating the overall rating.
- Well-led?
- Good
- Management and quality monitoring had improved. Care records, risk assessments and audits were more accurate and actions from checks were recorded and completed.
What inspectors found, July 2021
Rated Good; inspectors found safe care and better management after earlier breaches were put right.
This was an unannounced, focused inspection on 18 May 2021. Inspectors checked whether earlier problems with recruitment and management systems had been fixed. They spoke with people, relatives and staff, observed care, and reviewed care, medicine, staff and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough trained staff, safer recruitment checks, secure medicine systems, good infection control and suitable risk assessments. Records and quality checks had also improved.
The previous inspection had found two breaches and the service was not rated at that time. Inspectors found the improvements were enough for the home to no longer be in breach. The overall rating changed from Requires Improvement to Good, with other question ratings carried forward from the previous comprehensive inspection.
Enough trained staff
Inspectors saw enough staff on duty to respond to people's needs safely. People and relatives also said staffing levels were sufficient.
“Suitable numbers of trained and competent staff were deployed in order to meet people's care needs.” from the report
Infection control
The home was clean and had wide-ranging daily cleaning schedules. Inspectors were assured that infection risks, visits, testing and protective equipment were being managed.
“The service was clean and free from malodours.” from the report
Improved records and checks
Care records and risk assessments more accurately reflected people's needs. Audits covered areas including infection control, health and safety and medicines.
“Improvements had been made to people's records, including risk assessments and support plans so that these accurately reflected people's care needs and known risks to people.” from the report
Person-centred support
Staff and management supported people's individual communication, interests and preferences. Inspectors gave examples involving a person's first language and another person's former antiques business.
“People were encouraged to talk about their preferences and to be involved in decisions about their care.” from the report
Working with health professionals
The home worked with GPs, district nurses, dieticians and speech and language therapists. Referrals were arranged promptly when people's needs changed.
“Staff worked closely with health professionals such as district nurses and GPs to support people's health and well-being.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you continue to check new staff have the right recruitment and background checks before they start?
- 02How often are care records, risk assessments and medicine records reviewed and updated?
- 03What infection prevention, testing and visiting arrangements are currently in place?
- 04How do you make sure there are enough trained staff on each shift for my relative's needs?
- 05How would you respond if my relative's health or care needs changed and specialist support was needed?
This was a focused inspection of Safe and Well-led only; ratings for the other key questions were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 2 July 2021 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, November 2020
Inspected but not rated; inspectors found improvements, but recruitment checks and care records were still not reliable.
This was a targeted inspection on 17 September 2020. Inspectors checked specific concerns from the previous inspection, mainly recruitment, medicines and care records. They also checked infection prevention and control during the COVID-19 pandemic.
The home had improved, but important problems remained. One new staff member had been recruited without a completed application form, suitable references or written evidence of an interview. Some care and risk records were out of date or incomplete. Inspectors also found shortfalls in medicines practice, although the home addressed these immediately after the inspection.
People and relatives said they felt safe and were positive about the care. The home was clean and staff used protective equipment appropriately. The service was inspected but not rated, because this was not a full inspection of the key questions.
Infection control
Inspectors found no concerns about infection control. Staff used masks, gloves and aprons, and the home had measures for visitors, testing and managing outbreaks.
“At this inspection, we had no concerns around infection control.” from the report
Staff time and availability
People and staff said there were enough staff to meet people's needs. Inspectors saw staff spending time with people in a caring way.
“Staff told us they felt they had enough time to care for people.” from the report
Positive relationships
People, relatives and staff described kind relationships and a positive culture in the home.
“Relatives told us that people had been able to build up good relationships with the management team and staff.” from the report
Health and safety checks
The home was clean, tidy and free from unpleasant smells. Inspectors saw routine checks of the environment and equipment.
“The service was clean, tidy and odour free.” from the report
Recruitment checks
seriousThe home employed one new staff member without completing all the required checks. This was a continued breach of Regulation 19.
“The recruitment of new staff was not always safe.” from the report
Care and risk records
seriousSome records did not match people's current needs or risks. Information was also stored in different places, which could make it harder for staff to find important information.
“Some records for people were missing or had not been updated for a long period of time including risk assessments and guidance for staff administering medicines.” from the report
Medicines practice
needs fixingInspectors saw staff using a medicines practice that did not follow best practice. Guidance for injections and body maps for creams were also missing, although the provider said these issues would be addressed immediately.
“The administration of people's medicines did not always follow best practice.” from the report
Quality checks
needs fixingThe home's audits did not identify the record-keeping problems found by inspectors. Further improvements were needed in the provider's oversight of the service.
“However these had not identified the issues we found with record keeping and therefore were not effective in their use.” from the report
- 01What checks are now completed before any new staff member starts work, including references, an application form and an interview?
- 02How do you make sure care plans, risk assessments and emergency evacuation information reflect people's current needs?
- 03How is medicines information kept together so staff can find it easily and safely?
- 04What guidance is now in place for people who need daily injections or topical creams?
- 05How are your audits checking that previous record-keeping and recruitment problems have been fully corrected?
This was a targeted inspection of specific parts of Safe and Well-led, including infection control; the other key questions were not assessed and the previous ratings were not changed. This explanation was written from the published report of 14 November 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 Pinehurst Rest Home
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 26 November 2010.
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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