Pine Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment and Safeguarding people from abuse.
 

This service scored 34 (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 demonstrate a positive learning culture where incidents, accidents and concerns were consistently reviewed, understood and used to improve practice. Medication incidents represented the largest category of incidents reviewed, yet governance systems failed to identify medicines management as an emerging risk area. The provider’s incident analysis reviewed by the inspection, had concluded no trends had been identified despite the volume medication incidents.
Repeated seizure activity, recurring unexplained injuries and patterns of self-injurious behaviour were documented over extended periods without evidence that themes were identified, or learning was embedded into practice. The provider's incident analysis records did not reflect the recurring concerns we identified through inspection. Although incidents were often recorded individually, there was limited evidence that the provider consistently reviewed them collectively to identify trends, reduce future risk or improve outcomes. As a result, opportunities to learn from incidents and prevent recurrence were missed, exposing people to ongoing risks.
The provider repeatedly failed to recognise recurring patterns of concern despite information being available within incidents, daily records and family feedback. As a result, opportunities to identify emerging risks, implement preventative actions and reduce future harm were missed.
 

The provider did not always ensure information was shared effectively to support safe, coordinated care. Care records, risk assessments, medication records and supporting documentation were not always accurate, complete or reflective of people's current needs. We identified examples where information relating to one Service User appeared in another person's records and important information was not consistently reflected across documentation. For example, a bed rail assessment contained care information relating to a different service user, and a Mental Capacity Assessment repeatedly referred to another person throughout the document. These inaccuracies increased the risk of staff relying on incorrect information when planning and delivering care and reduced assurance that people's needs would be consistently understood and met.
Family feedback also highlighted concerns regarding handovers, communication between services and continuity of information when people attended respite stays. Relatives described instances where they had to initiate discussions to obtain information and where agreed communication arrangements were not consistently maintained. These concerns reduced assurance that people received coordinated care across different teams and services and increased the risk of important information being missed when planning and delivering support.
As a result, the provider could not demonstrate effective systems to ensure accurate information followed people throughout their care journey or that care remained coordinated, safe and consistent when needs changed or when information was shared between staff, families and partner services.
 

The provider did not work effectively with people and partner agencies to understand and manage safeguarding risks. We identified occasions where safeguarding concerns were not consistently recognised, escalated or reviewed. The provider did not have a consistent approach to ensuring Deprivation of Liberty Safeguards (DoLS) were in place before routine restrictive practices. A recurring pattern of unexplained injuries and incidents affecting people using the service did not always result in evidence of safeguarding review or wider analysis.
Although safeguarding training had been completed by staff and safeguarding policies were in place, inspection findings demonstrated these arrangements were not effective in practice. Staff and leaders did not consistently recognise incidents that may have required safeguarding consideration, and records did not always demonstrate concerns had been assessed, escalated or reviewed in line with the provider's safeguarding procedures. This reduced assurance that safeguarding training, policy implementation and management oversight were effective in promoting a culture of safeguarding awareness and accountability.
Family feedback identified concerns regarding environmental safety, implementation of agreed risk management arrangements and occasions where concerns required repeated raising before action was taken. We also identified incidents, allegations and injuries that may have required safeguarding consideration but did not clearly demonstrate effective review, escalation or learning. These concerns indicated safeguarding systems were largely reactive and did not consistently identify, assess and respond to emerging risks in a timely or effective way.
These failures reduced assurance that people were protected from abuse, neglect and avoidable harm. The provider could not consistently demonstrate safeguarding concerns would be recognised, investigated and escalated appropriately.

The provider did not always work effectively with people, relatives and professionals to understand and manage risk. Risk assessments and support plans were not always accurate, complete or reflective of current needs, reducing assurance that people's risks were fully understood and consistently managed. Family feedback highlighted concerns that agreed safety arrangements, routines and support plans were not always followed, particularly when unfamiliar staff were involved. Some relatives reported repeatedly raising concerns relating to risk management before action was taken.
We also identified examples where changing health needs, incidents and injuries did not consistently result in review of risk assessments or support arrangements. For example, repeated seizure activity and medication-related concerns affecting people using the service did not consistently trigger review of associated risk assessments or evidence that risk management strategies had been reconsidered with the person, their representatives or relevant professionals. Inspection also found documentation inaccuracies and inconsistencies which reduced assurance that staff had access to current risk information when supporting people.
As a result, we could not always be assured that risks were recognised, reviewed and managed in partnership with people and those important to them, or that risk management arrangements remained effective when people's needs and circumstances changed.
 

The provider did not always ensure environmental risks and safety arrangements were managed consistently. Family feedback identified concerns regarding the security of the service environment, including an occasion where a relative reported the front door had been found unlocked and unattended. A further concern was raised regarding equipment used to manage risk, where a relative reported a safety tracker for a person with a known absconding history was not always maintained in a charged state. We also identified wider governance concerns relating to oversight and monitoring of risks, which reduced assurance that environmental and equipment-related risks would always be identified and managed consistently.
However, the provider had appropriate systems in place for the management of many environmental risks. Premises, equipment and facilities were generally well maintained and supported the delivery of care. Previous environmental concerns identified through audits had been addressed, including improvements to secure storage arrangements and the physical environment. Staff had access to appropriate equipment to support people safely and there was evidence that maintenance issues were acted upon when identified.
Although environmental risks were usually identified and controlled, inconsistent implementation and oversight meant we could not always be assured that environmental and equipment-related risks would always be managed safely.
 

The provider did not always ensure staff had the skills, knowledge and competency required to meet people's needs safely. We identified weaknesses in oversight of medicines management competency, specialist training and clinical support requirements. Training records demonstrated gaps in compliance across some mandatory and specialist training areas, reducing assurance that staff had received training appropriate to the complex needs of people using the service. Inspection also identified examples where training completion and competency assurance had not been translated into consistently safe practice, particularly in relation to medicines management, risk management and the application of specialist support arrangements.
Family feedback highlighted differences between regular staff, who knew people well, and agency or unfamiliar staff, who did not always demonstrate the same understanding of people's routines, risks and preferences. Relatives reported concerns that agreed support arrangements were not always followed consistently when unfamiliar staff were involved. The concerns identified in medicines management, risk management and healthcare escalation limited assurance that staff always had the necessary knowledge, guidance and support to deliver safe and effective care.
However, families frequently described regular staff as caring, knowledgeable and committed. The provider had also begun implementing additional competency checks, training reviews, management oversight and external specialist support following the concerns identified. Whilst there was evidence of a committed workforce, the provider could not consistently demonstrate that all staff had received suitable training, maintained the required competencies or possessed the knowledge necessary to safely always meet people's individual needs.
 

The provider did not always assess and manage infection prevention and control risks effectively. We identified gaps in oversight and documentation relating to infection prevention and control. Records did not always clearly demonstrate that infection risks associated with people's individual health needs had been consistently reviewed, monitored and updated. In addition, governance systems did not always provide assurance that infection prevention and control arrangements were being effectively audited or that identified concerns would be recognised and acted upon in a timely way.
For example, inspection identified concerns regarding the management and escalation of a service user's deteriorating leg condition. Records described the leg as becoming cold, painful, red and sore over a two-day period, however there was no evidence that timely medical advice had been sought or that the potential infection risk had been formally assessed and escalated. This reduced assurance that emerging infection risks and signs of deterioration would be consistently recognised, monitored and acted upon by staff.
However, the service environment was generally clean and well maintained. Staff had access to appropriate personal protective equipment, and there was evidence of cleaning schedules, infection prevention procedures and environmental checks being completed. There was no evidence of a widespread infection outbreak or significant environmental hygiene concerns at the time of inspection.
Whilst arrangements were in place to reduce the risk of infection, weaknesses in oversight and monitoring meant the provider could not consistently demonstrate that infection prevention and control risks were being effectively assessed, reviewed and managed.
 

The provider did not ensure medicines were consistently managed safely or in a way that met people's individual needs. We identified a recurring pattern of medicines concerns affecting multiple people over an extended period, including medication administration errors, dosing errors, inaccurate allergy recording and failures to appropriately escalate medicines-related concerns. Family feedback described missed medication, delays in communicating medication concerns and failures to consistently follow agreed medication administration arrangements. Inaccuracies and inconsistencies were identified across care records, medication administration records (MAR) and supporting medication documentation, reducing assurance staff always had access to accurate information when supporting people with medicines. Although staff sought clinical advice following some incidents, the provider could not demonstrate effective oversight, learning or improvement in response to recurring medicines concerns.
The provider could not consistently demonstrate that people received medicines safely and as intended. As a result, people were exposed to avoidable risks including medication errors, delayed treatment leading to a possible deterioration in health.