Pine Lodge

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.
At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes. The service was in breach of legal regulation consent to care and treatment.
 

This service scored 33 (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 did not consistently ensure people's health, care, wellbeing, communication and support needs were fully assessed, accurately recorded or regularly reviewed. Our records review identified care plans, risk assessments and supporting documentation that contained inaccuracies, omissions, contradictory information and information relating to other people. The provider completed preadmission checks prior to each stay, but families told us that this was more a tick box exercise and was not always completed. Mental Capacity Assessments were not always completed appropriately, and some had been signed as complete despite significant gaps. This reduced assurance that staff always had access to accurate and current information about people's needs. Family feedback also highlighted concerns that unfamiliar staff did not always understand people's established routines, preferences or health needs to the same extent as regular staff. Whilst some care records contained detailed person-centred information and regular staff were often described positively by relatives, the provider could not demonstrate that people's needs were consistently assessed, reviewed and translated into effective care planning. As a result, care and treatment did not always reflect people's current needs and circumstances.

The provider did not consistently plan and deliver care and treatment in line with current legislation, recognised guidance, best practice or people's assessed needs. Inspection identified multiple examples where care delivery and documentation did not reflect expected standards of practice. These included incomplete and inconsistent Mental Capacity Act documentation, restrictive interventions being used without supporting decision-making records, inaccurate allergy information, and failures to ensure healthcare interventions and specialist recommendations were consistently reflected within care records and risk assessments.
We identified occasions where changes in people's needs, health conditions and clinical presentation did not result in corresponding review of care planning, risk management arrangements or healthcare involvement. Family feedback highlighted examples where agreed approaches to supporting people, including dietary requirements, communication arrangements and individual routines, were not consistently followed by all members of staff.
Although there were examples of person-centred care and many relatives spoke positively about the support provided by regular staff, the provider could not demonstrate that care and treatment were consistently planned, delivered and reviewed in accordance with current legislation, recognised standards and evidence-based practice. As a result, people were not always assured that their care and treatment reflected current needs, best practice and professional guidance.
 

The provider did not always work effectively across teams, services and partner organisations to ensure people received coordinated care and support. We found information received from healthcare professionals, incidents and changes in people's needs did not consistently result in timely review of care plans, risk assessments or support arrangements. Family feedback highlighted concerns regarding handovers, communication between services and occasions where external services identified concerns that required follow-up before action was taken. Relatives also reported that continuity of information was not always maintained when different staff were involved. However, there was evidence that staff engaged with healthcare professionals when concerns were identified, and families generally described regular staff as approachable and willing to liaise with them regarding people's needs. Whilst multidisciplinary working occurred, the provider could not consistently demonstrate that information was effectively shared, acted upon and embedded into care delivery across all teams and services involved in people's care.

The provider did not always support people to effectively manage their health and wellbeing or ensure they received timely support when their health needs changed. Inspection identified examples where signs of deterioration, recurring symptoms and changes in health status did not consistently result in timely healthcare escalation or review. Records demonstrated occasions where seizures, injuries and other health concerns were not always reviewed or acted upon appropriately. Family feedback also highlighted concerns that some unfamiliar staff did not always have the same level of understanding regarding people's health needs and established care arrangements as regular staff. However, some records showed people were supported to access healthcare services when concerns were recognised, and relatives spoke positively about the commitment of regular staff. Whilst people were often supported to maintain their health and wellbeing, the provider could not consistently demonstrate that changing health needs were recognised, reviewed and acted upon promptly, reducing assurance that people received coordinated support to maximise their health and quality of life.
Failure to consistently recognise and respond to deteriorating health conditions increased the risk that people would not receive timely treatment and could experience worsening health outcomes.
 

The provider did not routinely monitor people’s care, treatment and experiences to ensure outcomes were positive, consistent and continuously improving. Whilst the provider had audit systems, incident reporting processes, governance meetings and service improvement plans in place, these arrangements did not provide effective assurance regarding the quality and safety of care.
For example, a Customer Stay Audit completed for 1 person achieved a score of 100% and an overall rating of “Outstanding”, despite our inspection identifying significant concerns within the same records. Including, gaps in Mental Capacity Act documentation, restrictive practice decision-making, medicine management and monitoring arrangements. The provider’s own audit tools did not identify these concerns and therefore did not provide effective oversight of care quality.
We found a provider quality assurance tool designed to collate evidence of compliance had not been effectively utilised, reducing assurance that information regarding quality, safety and outcomes was being systematically reviewed. In addition, improvement plans relating to medicines management contained a number of overdue actions, despite medicines incidents representing the largest category of incidents reviewed. This demonstrated that concerns previously identified had not consistently resulted in sustained improvement.
Family feedback further indicated some concerns were only resolved following intervention from relatives or external services rather than being identified through the provider’s own monitoring systems. Relatives described occasions where issues had to be repeatedly raised before action was taken and where improvements were driven by external challenge rather than internal review.
Monitoring arrangements therefore did not provide reliable assurance regarding the quality, safety or effectiveness of care. As a result, the provider could not demonstrate outcomes for people were being routinely monitored, evaluated and improved, or that lessons learned were consistently translated into safer and more effective care.

The provider did not consistently ensure people's rights in relation to consent were understood, respected and applied in accordance with the Mental Capacity Act 2005. Our records review identified multiple Mental Capacity Assessments were incomplete, contradictory or signed as completed despite significant omissions. Records did not always clearly demonstrate how capacity had been assessed, how decisions had been reached or how people had been supported to participate in decision-making. Restrictive interventions were not always supported by appropriate Mental Capacity Assessments, best-interest decision-making processes or evidence that less restrictive options had been considered. In some cases, supporting documentation was incomplete or absent, reducing assurance that restrictions placed upon people were lawful, necessary and proportionate. Although there were examples of staff involving people and families in decisions, the provider could not demonstrate that consent and Mental Capacity Act requirements were consistently met. As a result, people could not always be assured that their rights were protected or that care and treatment were delivered in accordance with legal requirements and best practice.