CQC report explained · a nursing home
What the CQC found at Pinewood Residential 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, October 2019
Rated Good overall, but inspectors found safety needed improvement, including medicine administration and conflicting care records.
This was an unannounced inspection on 6 and 7 August 2019. One inspector and an expert by experience spoke with people, relatives, staff and health professionals. They also observed care and checked care, medicine, staff and management records.
The home was rated Good overall. Effective, caring, responsive and well-led were all rated Good. Safe was rated Requires Improvement, which means some aspects were not always safe and there was limited assurance about safety.
Inspectors found kind and respectful care, enough staff on duty, good activities, suitable food and support from health professionals. However, computerised and paper care records did not always match, and staff were interrupted during medicine rounds. The home had taken action, but improvements were still in progress.
Kind and respectful care
People were treated with dignity and respect. Staff supported people at their own pace and helped them make everyday choices.
“People were treated with compassion, dignity and respect and we saw this throughout the inspection.” from the report
Activities and social life
The home offered daily activities, trips out and one-to-one support based on people's interests and wishes.
“Activities took place within the home on a daily basis and included visiting musicians, exercise, arts and crafts, visiting birds of prey and visits from the 'library ladies', who brought people books.” from the report
Staffing and recruitment
Inspectors saw enough staff on duty to meet people's needs. Recruitment checks were carried out to help prevent unsuitable staff being employed.
“Throughout the inspection we observed there were sufficient staff on duty to meet people's needs and spend time socialising with them.” from the report
Open management
The managers were visible, knew people well and encouraged people, relatives and staff to share their views.
“The registered manager and provider were highly visible at the service.” from the report
Conflicting care records
seriousPaper and computerised records did not always give the same instructions about people's risks and care. This created a potential for staff error.
“Although risks were well understood and managed by staff, there was a potential for error.” from the report
Interruptions during medicines
seriousThe staff member giving medicines was interrupted by visitors and requests for help. The home told inspectors that staff had been reminded to use interruption-reducing tabards and follow the process.
“The member of staff administering the medicines was unable to focus fully on the task because they were talking with visitors and responding to requests for staff support.” from the report
Incomplete care planning
needs fixingSome computerised care plans lacked personal information or had reviews that were not complete. The home was sourcing a new system and using paper summaries in the meantime.
“One care plan contained no information about the person's background and interests.” from the report
Quality checks had fallen behind
needs fixingSome quality assurance checks and audits had not been completed on time. The home was catching up and reviewing its systems.
“The focus on maintaining the staffing levels and safety of people over the previous 12 months meant the registered manager had fallen behind with some of the quality assurance checks and audits.” from the report
- 01How do you now make sure the paper and computerised care records contain the same risk information?
- 02What is your current process for preventing interruptions during medicine rounds?
- 03Has the new computerised care planning system been introduced, and are all care plans now complete and reviewed?
- 04Have the quality checks and audits that had fallen behind now been completed?
- 05How do you make sure agency and newly recruited staff know each person's risks, preferences and care needs?
This was an unannounced planned inspection covering all five CQC questions, with the Safe rating falling from Good to Requires Improvement and the other ratings remaining Good. This explanation was written from the published report of 31 October 2019 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, March 2017
Rated Good; inspectors found kind, safe care, with some records and medicine guidance improved during the inspection.
This was an unannounced comprehensive inspection over two visits on 18 and 30 January 2017. Inspectors spoke with people living there, visitors, staff and health professionals. They reviewed care records, medicine records, staff files, audits and meeting notes.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine systems, suitable training and kind treatment. People were involved in their care and had access to activities, food choices and healthcare.
Some improvements were made during the visits. Guidance for applying prescribed creams was restored, care plans for emotional and psychological needs were added where needed, and records of fluid intake were strengthened. A previous legal breach about inaccurate care records had been addressed.
Kind and respectful staff
Inspectors saw warm and compassionate interactions. Staff supported people's dignity, choices and independence.
“People were supported by kind and caring staff who treated them with warmth and compassion.” from the report
Enough staff
Staffing arrangements had been changed so duties were shared more evenly. People said call bells were answered quickly.
“There were sufficient numbers of staff on duty to keep people safe.” from the report
Activities and choice
People could follow their interests and join activities or outings. Daily routines were flexible, including choices about getting up, going to bed and where to spend time.
“People confirmed the daily routines were flexible and they were able to make decisions about the times they got up and went to bed” from the report
Open management
The new manager was visible and approachable. People, relatives and staff had regular opportunities to give feedback and suggest changes.
“There were regular opportunities for people and relatives to share their views.” from the report
Topical cream records
seriousInspectors found that staff could not always record whether prescribed topical creams had been given because the information had been removed from the computer system. This was restored by the second visit.
“Improvements were needed in relation to the administration of topical creams, as this was not always safe.” from the report
Emotional care plans
needs fixingCare plans did not always cover people's emotional and psychological needs. The managers added the missing plans during the inspection and planned a wider care-record audit.
“We discussed with the manager that there was not an emotional and psychological care plan for one person who was receiving end of life care.” from the report
Mental capacity records
needs fixingMental capacity assessments and best-interest decisions were being completed, but the details were not yet captured on the computerised care system. The manager was working with the software company to improve this.
“However this information was not captured on the computerised care system.” from the report
Some worn areas
minorSome corridors were shabby and scuffed and needed decorating. The report says redecoration and other improvements were planned or already under way.
“Some areas of the home such as corridors were shabby and scuffed and in need of decorating.” from the report
- 01How do you now check that prescribed topical creams are recorded and applied correctly?
- 02Have all people's emotional and psychological care plans been reviewed and kept up to date?
- 03How are mental capacity assessments and best-interest decisions recorded now?
- 04What progress has been made with decorating the shabby and scuffed corridors?
- 05How will the new manager's improvement plan be monitored and shared with families?
This was an unannounced comprehensive inspection covering all five CQC questions and the overall quality of the service. This explanation was written from the published report of 8 March 2017 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 Pinewood Residential Home
3 rated inspections over 5 years: the service has held its Good rating throughout.
- October 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 January 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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