CQC report explained · a residential care home
What the CQC found at The Pines (Active Prospects)
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection prevention and control arrangements were effective. They also considered how the home was managing COVID-19-related staffing pressures.
- Effective?
- Good
- This key question was not assessed in this targeted inspection.
- Caring?
- Good
- This key question was not assessed in this targeted inspection, although inspectors described support that reflected people's needs and preferences.
- Responsive?
- Good
- This key question was not assessed in this targeted inspection, although people were supported to maintain contact with loved ones and take part in activities they liked.
- Well-led?
- Good
- This key question was not assessed in this targeted inspection.
What inspectors found, January 2022
Inspected but not rated; inspectors found good infection control and support for people during the COVID-19 pandemic.
This was a targeted inspection on 20 January 2022. It was announced 24 hours beforehand and focused on infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19.
Inspectors found that people were supported to stay in contact with loved ones, go out safely when possible and enjoy activities suited to their likes and sensory needs. Staff understood people's needs and what mattered to them.
Inspectors were assured that infection risks were being managed. This included the use of protective equipment, testing, visiting arrangements, cleaning, outbreak planning and COVID-19 vaccination requirements for relevant staff and visiting professionals.
The service was inspected but not rated. This means the report does not give a new overall rating or a rated result for the five key questions.
Support during the pandemic
People were supported to maintain relationships, go out safely when possible and continue activities suited to their preferences and sensory needs.
“People were supported in a way which minimised the impact of the pandemic on their lives.” from the report
Infection control
Inspectors were assured that the home used protective equipment, testing, hygiene measures and visiting arrangements appropriately.
“We were assured that the provider was using PPE effectively and safely.” from the report
Outbreak planning
There were clear plans for managing an infection outbreak, with relevant external partners consulted about people's specific needs.
“There were clear plans on how an outbreak of infection would be managed which were consulted with relevant external partners” from the report
Staff support and training
Staff said they felt supported and valued. They had access to protective equipment and infection prevention and control training.
“Staff told us they felt supported and valued by the management and had ongoing access to the personal protective equipment” from the report
Inspectors raised no specific concerns in this report.
- 01How are any current staffing pressures affecting the support people receive?
- 02How are visits currently being arranged, and what infection control measures apply to visitors?
- 03How do you make sure activities continue to reflect each person's likes and sensory needs?
- 04What is the current plan for managing an infection outbreak, and how would each person's specific needs be supported?
- 05When was the service last given a full inspection and an overall rating?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other key questions or give a new overall rating. This explanation was written from the published report of 28 January 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 2019
The Pines (Active Prospects): Rated Good; inspectors found safe, kind and person-centred care, with some records needing improvement.
This was an unannounced inspection by two inspectors on 29 October 2019. They observed care, spoke with staff and the manager, reviewed care, medicine, recruitment and management records, and contacted relatives and visiting professionals afterwards.
The home supported six people with profound learning disabilities and complex physical health needs. Inspectors found enough trained staff, safe medicines practices, suitable risk assessments and good links with health professionals. People were treated with kindness, involved in choices and supported to develop independence, communicate and take part in activities.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found two recording issues. Some best-interest records did not show who had been involved, and three incidents had not been reported to CQC as required. The records were updated or the notifications submitted after inspectors raised these points.
Kind and respectful care
Staff spent time with people, understood their signs of happiness or distress and protected their dignity and privacy.
“Staff were caring, kind and respectful to people and their families.” from the report
Support for independence
People were encouraged to make choices, move around safely, learn skills and take part in activities in the home and community.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Safe medicines and risk management
Medicines records were complete, staff were trained and people's individual risks had clear guidance for staff.
“Medication administration records (MAR) were fully completed by staff.” from the report
Good communication support
Care plans explained how people communicated, and staff used aids such as pictures, social stories and voice recordings.
“Care plans included detailed information on how people communicate and what their individual behaviours meant.” from the report
Learning and improvement
Management audits led to actions such as quicker repairs and better checks on food storage. Incidents were reviewed for learning.
“The registered manager used effective systems of quality assurance and governance.” from the report
Missed CQC notifications
needs fixingThree incidents that should have been reported to CQC had not been reported when inspectors checked. The notifications were submitted after the issue was raised.
“However, we found that the registered manager had not always reported incidents to CQC in line with legal requirements.” from the report
Incomplete best-interest records
needs fixingSome records did not show who had taken part in best-interest decisions, including relatives and social workers. The records were updated during the inspection.
“However, best interest decisions did not always record who was involved in the decision making process, such as next of kins and social workers.” from the report
- 01How do you now check that every incident which must be reported to CQC is notified on time?
- 02How do your best-interest records show which relatives, social workers and other people were involved?
- 03How do you make sure staffing levels and staff continuity meet each person's changing needs?
- 04Which communication aids and methods would be used for my relative?
- 05How are medicines errors, including as-needed medicines, audited and acted on now?
This was an unannounced planned inspection covering all five key questions; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 17 December 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.
Every inspection of The Pines (Active Prospects)
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at The Pines (Active Prospects) →
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at The Pines (Active Prospects) →
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 3 November 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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77 live-in carers within about an hour of Surrey
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Most charge £980 to £1,250 a week. 66 can care for a couple. 11 years' experience on average.
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