CQC report explained · a residential care home
What the CQC found at The Pines Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were regularly reviewed, medicines were managed safely and fire drills had improved. They noted that some small toilet windows still did not have restrictors, although the report said the risk was low.
- Effective?
- Good
- Staff training and supervision had improved. Care plans were regularly updated, dietary needs were supported and people were helped to access health professionals.
- Caring?
- Good
- This question was not covered by this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Requires improvement
- This question was not covered by this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Management checks and audits had improved. Staff said the home was better organised and that they felt supported, although the manager was still applying to become formally registered.
What inspectors found, September 2020
The Pines Residential Care Home was rated Good after inspectors found clear improvements, with a small remaining concern about window safety.
This was a focused inspection on 1 September 2020. One inspector spoke with three people living at the home and five staff members. They reviewed care records, medicines records, staff files and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found better risk checks, regular fire drills, safer medicines systems, up-to-date training and improved care planning. Infection control measures and protective equipment were also in place during the COVID-19 pandemic.
The home had previously been rated Requires Improvement, with breaches involving person-centred care, safe care and treatment, staffing and leadership. Inspectors found enough improvement for the home to no longer be in breach of those regulations.
This inspection did not cover Caring or Responsive. Those ratings were carried forward from the previous comprehensive inspection.
Improved safety checks
The home had fitted window restrictors in upstairs bedrooms and introduced more regular fire drills. Risks relating to people's health and support were reviewed as needs changed.
“At this inspection we saw that detailed and regular drills were now taking place.” from the report
Safer medicines and infection control
Medicines audits and staff competency checks were carried out. The home was clean, had enough protective equipment and staff were observed using it effectively.
“The home had a sufficient supply of protective equipment and we observed staff wore PPE effectively.” from the report
Better staff support
Training and supervision were being monitored more closely. Staff said they received better support and reminders about completing training.
“Staff told us they were now well-supported with training and reminded when this needed to be completed.” from the report
Updated care planning
Care plans gave clearer guidance, reflected professional advice and included people's preferences and choices. Staff said they understood the care people needed.
“Care plans were regularly reviewed and updated to reflect the guidance provided by health professionals.” from the report
More effective management
Quality checks had improved and the manager understood what still needed attention. Staff described the home as better organised and run.
“Quality processes had been improved and there was increased monitoring.” from the report
Some toilet windows lacked restrictors
needs fixingSmall windows in toilet areas did not have restrictors. Inspectors considered the risk low but asked the manager to consider fitting restrictors or putting risk assessments in place.
“Toilet areas had small windows which did not have restrictors fitted.” from the report
Manager registration was not complete
minorThe previous registered manager had left but remained registered with the CQC. A new manager was applying for registration, and the application was still being processed at the inspection.
“A new manager was in place and was actively pursuing registration with the CQC.” from the report
- 01Have restrictors now been fitted to the small toilet windows, or what risk assessments are in place?
- 02Has the new manager's CQC registration been completed?
- 03What was the previous rating for Caring and Responsive, and what has changed in those areas since that inspection?
- 04How is staff training monitored under the new training system?
- 05How are garden visits and contact with relatives being managed while COVID-19 restrictions apply?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried forward. This explanation was written from the published report of 25 September 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.
What inspectors found, January 2020
The Pines Residential Care Home was rated Requires Improvement; inspectors found kind care and safer medicines, but serious gaps in risk management, staff training and leadership.
This was an unannounced inspection over two days. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care records, medicine records, staff files and management records, and observed care.
The home was under organisational safeguarding because of several concerns. Inspectors found risks were not always managed, fire drills were not up to date, staff training records had significant gaps, and care plans did not always reflect professional advice. They also found the provider's checks had not identified these problems.
People were treated with kindness and respect. Medicines were managed safely, staffing and recruitment were suitable, and people had access to health professionals. However, the overall rating fell from Good to Requires Improvement, with four of the five areas rated Requires Improvement.
Medicines had improved
There were no gaps in medicine administration records. Stock checks matched the records, and staff had received additional training and competency checks.
“We found that management of medicines had improved.” from the report
Safe recruitment and staffing
People, visitors and professionals said there were enough staff to provide timely care. Recruitment checks were carried out appropriately, including risk assessments where needed.
“The provider had appropriate staff recruitment process in place.” from the report
Access to health support
Care records showed people were supported to see health and social care professionals. Professionals said staff made appropriate referrals for advice and support.
“People's care files showed they were supported to have access to a range of health and social care professionals and facilities.” from the report
Risks and fire safety
seriousSome safety risks were not managed promptly or clearly recorded. Upper-floor windows were unsafe at the time of inspection, and fire drills had not been carried out regularly.
“The provider had not made sure robust safety measures were in place. This placed people at risk of potential harm.” from the report
Staff training gaps
seriousTraining records were incomplete, with notable gaps in important subjects. There was no robust system to alert managers when training needed renewal.
“Staff had not received the appropriate training and professional development needed to enable them to carry out their duties.” from the report
Care did not always follow professional advice
seriousCare plans were not always updated after professional advice changed. Staff did not always follow guidance about specialist diets and other care needs.
“Care was not always delivered in line with professional guidance.” from the report
Weak management checks
seriousAudits were often tick-box exercises and failed to identify problems found by inspectors. There was no clear evidence of formal provider oversight.
“Systems were either not in place or robust enough to demonstrate management and oversight of the home was effective or robust.” from the report
Limited activities and care reviews
needs fixingRecorded activities were limited, and activities were not always adapted when people's needs changed. Care reviews and end of life plans often lacked detail.
“Records indicated other activities were limited.” from the report
- 01What action has been completed to make sure all care plans reflect current professional advice, including specialist diets and occupational therapy guidance?
- 02How are fire drills, evacuation skills and other safety checks now scheduled, recorded and reviewed?
- 03Which staff training gaps identified in the report have been closed, and how do you check that training stays up to date?
- 04How has the provider strengthened audits and formal oversight so that risks and care quality problems are identified promptly?
- 05How are activities and end of life plans now personalised to each person's changing needs?
This was an unannounced inspection covering all five CQC questions; the previous Good ratings for each area were reassessed, with Caring remaining Good and the other four areas falling to Requires Improvement. This explanation was written from the published report of 17 January 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 The Pines Residential Care Home
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- September 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at The Pines Residential Care Home →
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Pines Residential Care Home →
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- September 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.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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