CQC report explained · a nursing home
What the CQC found at The Pines Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks, staffing, recruitment, safeguarding and medicines were managed safely. Infection prevention and control arrangements were also checked and found satisfactory.
- Effective?
- Good
- Staff had a thorough induction and regular refresher training. People received suitable food and healthcare support, although individual staff supervision was not regular for everyone.
- Caring?
- Good
- People and relatives described staff as friendly, kind and respectful. Inspectors observed staff protecting people's privacy, dignity and choices.
- Responsive?
- Good
- Care plans covered people's needs, communication, activities and end of life wishes. Some information was split between paper and electronic records while the new care planning system was being completed.
- Well-led?
- Good
- The home had audits, meetings and systems for learning from incidents and feedback. People, relatives and staff described an open culture and approachable managers.
What inspectors found, July 2022
Rated Good; inspectors found safe, kind and responsive care, but staff supervision and care record transfers needed attention.
The CQC made an unannounced inspection visit on 20 June 2022. One inspector, a nurse specialist adviser and an Expert by Experience carried out the inspection. They spoke with people living in the home, relatives and staff, and reviewed care records, staff files, training records, audits and other documents.
Inspectors found that people were safe, treated with kindness and supported to have their health, care and communication needs met. Staffing levels, medicines, safeguarding, infection control and risk management were found to be good. People had activities, could give feedback and had complaints dealt with in a timely way.
There were two areas needing improvement. Individual staff supervision was not happening regularly for everyone. Some information had not been fully moved from the old care planning system to the new one, making records harder to find. The home had action plans to address these issues.
The home was rated Good overall and Good in all five key questions. Safe improved from Requires Improvement at the previous inspection, while Effective, Caring, Responsive and Well-led remained Good.
Safe staffing
Inspectors found enough staff on duty and saw that staffing rotas matched the home's dependency assessment.
“We reviewed staff rotas for the three weeks prior to the inspection and saw that the number of staff deployed to work at the home matched the levels on the dependency tool.” from the report
Safe medicines
Medicines were stored securely, given by trained staff and recorded accurately.
“Medicines were managed consistently and safely in line with national guidance.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors observed patient and respectful support during personal care and meals.
“We observed kind interactions between staff and people using the service, during group activities and at mealtimes.” from the report
Good activities and feedback
People had access to individual and group activities linked to their interests. The home sought views through meetings, surveys and other feedback.
“People and their relatives told us there was a good range of activities available to them.” from the report
Quality monitoring
The home used audits, meetings and improvement plans to monitor care and respond to risks or feedback.
“There was a system of quality assurance audits in place to help monitor the quality of service that people received.” from the report
Staff supervision
needs fixingIndividual one-to-one supervision meetings were not taking place regularly for all staff. Managers provided an action plan and said sessions had been booked.
“Although the provider held team meetings, we found individual 1:1 supervisions did not take place regularly for all staff.” from the report
Care records being transferred
needs fixingThe move to a new care planning system was incomplete. Information was sometimes split between paper and electronic records, making it harder to locate.
“Information seemed to be both in paper notes and on records, so was sometimes difficult to locate.” from the report
- 01Has all information now been transferred from the old care planning system to the new one?
- 02How do you make sure staff receive regular individual supervision?
- 03How are staffing levels reviewed when people's needs change?
- 04How do you check that medicines continue to be given and recorded safely?
- 05How are people's activity choices and feedback used to change the care provided?
This was an unannounced inspection assessing all five key questions, with a specific check of infection prevention and control; the report refers to the previous inspection as the last comprehensive inspection. This explanation was written from the published report of 29 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, September 2018
Rated Good overall, but Safe requires improvement because medicines, pain assessments and recruitment checks were not always fully managed.
This was an unannounced comprehensive inspection on 4 and 10 July 2017. Inspectors spoke with people living in the home, relatives, staff and managers. They examined care records, medicines records, staff files, training records, complaints and quality checks.
Overall, the home was rated Good. Inspectors found kind and respectful care, suitable support with health needs and food, personalised care plans, activities and a responsive complaints process. Staff were described as supportive, and the home had regular checks on quality.
Safe was rated Requires Improvement. Some medicines were used beyond their recommended shelf life, staff did not always use the pain assessment tool correctly, and recruitment checks were inconsistent. The report says the home took immediate action on some issues during or after the inspection.
Kind and respectful care
People said staff were friendly, respected their privacy and allowed them to make choices about their daily routines.
“People said that care workers were friendly and respected their privacy.” from the report
Personalised care plans
Care plans set out people's needs, preferences and the support staff should provide. Records showed that plans were reviewed and people's wishes were followed.
“Each care plan had an identified need, a plan of action to manage the need and the steps that staff needed to take to support the person.” from the report
Medicine administration records
People received medicines on time, and the records inspected showed no missed doses or gaps. The home also carried out regular medicine audits.
“The MAR charts and the monthly audits showed that there had been no incidents of missed doses and there were no gaps in the records we saw.” from the report
Staff training and support
New staff completed induction training, and existing staff were offered regular training and supervision.
“The training matrix showed that the provider was ensuring that its staff were offered regular training and were taking up the training opportunities on offer.” from the report
Quality checks
The home used regular audits, management visits, meetings and observations to check care and identify areas for follow-up.
“The provider had systems in place to monitor the quality of service and drive improvements.” from the report
Medicines past opening dates
seriousTwo medicine bottles had no opening dates and were still being used after the recommended period. Staff disposed of the medicines and ordered replacements when inspectors raised this.
“On two bottles the medicines were still in use after the recommended use by dates of opening.” from the report
Pain assessments
needs fixingStaff were not familiar enough with the pain assessment tool, and it was not always used effectively. The manager said pain management training had been arranged.
“However, we found that staff were not familiar with the pain assessment tool and its use.” from the report
Recruitment checks
needs fixingSome references were not properly verified and gaps in employment history were not always explored. Inspectors recommended stronger recruitment checks.
“We found there was some inconsistency with the recruitment checks.” from the report
Crushed medicines approval
seriousSome medicines were crushed without evidence that a pharmacist had approved this. The home obtained the necessary approval immediately after inspectors raised the issue.
“There was no evidence that the pharmacist had approved the crushing of medicines.” from the report
Incomplete pre-admission information
minorSome pre-admission forms did not fully record people's preferences. This could make it harder to plan care around what matters to a new resident.
“Some preadmission forms where not completed thoroughly, for example details about people's preferences were missing.” from the report
- 01What checks are now in place to make sure all medicine bottles and creams are dated when opened and discarded on time?
- 02How do you check that staff use the pain assessment tool correctly, and what training has been completed?
- 03How are references verified and gaps in employment history investigated before staff start work?
- 04What pharmacist approval is recorded when medicines are crushed, and how is this checked?
- 05How do you make sure each new resident's preferences are fully recorded before admission?
This was a comprehensive inspection covering all five questions, based on visits on 4 and 10 July 2017. This explanation was written from the published report of 19 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 The Pines Nursing Home
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodResponsive: Good
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 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.
- April 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 22 December 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Wandsworth
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 77 can care for a couple. 11 years' experience on average.
“She cared for my mum with Alzheimer's with endless patience and kindness, always arriving with a smile and a positive attitude”
“Without his support we wouldn't have been able to navigate bringing and keeping Dad at home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.