Pine Lodge

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider treated people with kindness, empathy and compassion, and respected their privacy and dignity. Staff treated colleagues from other organisations with kindness and respect. During our inspection, we carried out a Short Observational Framework for Inspection (SOFI) to observe the experiences of residents and the quality of interactions between staff and residents and observed positive interactions between staff and people using the service. Staff engaged people in meaningful conversations, responded warmly to requests for support and demonstrated familiarity with people's communication styles and preferences. One person told us, “My staff are kind and friendly." Families frequently described staff as caring, supportive and committed, and many spoke positively about the relationships people had developed with regular members of staff. We observed staff supporting people in a way that promoted dignity, privacy and wellbeing. Although concerns were identified in other areas of the service, there was consistent evidence that staff treated people with kindness and respect and were committed to making people feel comfortable and supported during their respite stays.
 

The provider did not always ensure support reflected people's individual needs, routines and preferences. Relatives told us regular staff generally knew people well, but agency or unfamiliar staff did not always follow agreed approaches to support. Family feedback identified examples where routines, dietary requirements and preferred ways of providing support were not consistently followed.
For example, one relative raised concern that packed lunches provided during respite stays did not consistently reflect the person's known dietary requirements and preferences. The concern was ultimately identified and addressed through intervention from an external day service rather than through the provider's own monitoring processes. This reduced assurance that staff consistently understood and implemented information important to the person's wellbeing, preferences and day-to-day support needs.
However, many families described regular staff as knowing people well and understanding what mattered to them. During the inspection we observed staff offering choice and adapting support to individual preferences. Whilst there were examples of person-centred care, the provider could not consistently demonstrate that all staff had sufficient knowledge of people's needs to ensure support was always tailored to the individual.
 

The provider did not always promote people's independence, choice and control by ensuring support consistently reflected their wishes, preferences and rights. We identified concerns regarding the consistency of care planning and decision-making documentation, reducing assurance that people's views and preferences were always clearly understood and acted upon.
Family feedback identified occasions where agreed support arrangements and routines were not followed consistently, particularly when unfamiliar staff were supporting people. A relative told us staff had been advised that their family member should not access the kitchen unsupervised due to identified risks but said, but he was allowed access every time "I've had to remind them several times about the kitchen arrangement because not everybody follows it." This reduced assurance that people's agreed support arrangements, preferences and safety measures were consistently respected regardless of which staff were providing support.
However, many relatives told us regular staff knew people well and supported them to make choices about daily activities and routines. During the inspection we observed staff offering choices, respecting preferences and supporting people in a respectful and person-centred way.
Whilst there were positive examples of promoting independence, the provider could not consistently demonstrate that all staff had the knowledge and information necessary to ensure people's choices, preferences and established routines were always recognised, respected and reflected in the support they received.
 

The provider did not always recognise and respond appropriately to people's immediate needs, changing circumstances and emerging concerns. Family feedback identified occasions where important updates were not communicated promptly, including medicine refusals only being reported after a person's stay had ended. Relatives also described difficulties obtaining timely information regarding respite arrangements and reported agreed communication tools were not always completed.
Inspection identified examples where concerns affecting people's wellbeing and safety did not consistently result in timely review, escalation or follow-up. For example, incidents involving unexplained injuries were recorded but there was not always evidence that the circumstances had been fully reviewed or that support arrangements had been reconsidered following the incident. We also identified occasions where behavioural incidents and distress-related events were documented within daily records, however records did not consistently demonstrate that these incidents had been analysed, escalated or used to inform immediate changes to support.
Family feedback further demonstrated occasions where concerns had to be raised repeatedly before action was taken and where important information affecting people's care was not shared promptly with relatives.
Although people and relatives frequently described staff as caring and supportive, the provider could not consistently demonstrate that systems and communication processes ensured people's immediate needs, changing circumstances and emerging concerns were recognised and acted upon without delay. As a result, people could not always be assured they would receive responsive support when needed.
 

The provider did not always support and enable staff to deliver high-quality, person-centred care consistently. We found weaknesses in competency oversight, governance and communication systems, reducing assurance staff always had the information and support needed to meet people's needs effectively. Inspection identified gaps in supervision, competency assurance and oversight processes, including medicines competency checks and monitoring of specialist skills. In addition, significant concerns identified during the inspection, including record keeping deficiencies, medicines management concerns and inconsistencies in risk management, had not been recognised through management oversight processes. This reduced assurance that staff were consistently receiving the guidance, feedback and development required to support safe practice.
One staff member told us, “I feel I have been given the chance to grow." Families also described regular staff as committed and caring. Following the inspection, the provider took additional steps to strengthen training, competency assessments and management oversight. Whilst there was evidence of a committed workforce, the provider could not consistently demonstrate all staff were sufficiently supported and equipped to always deliver safe and effective care.