Pine Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 culture that consistently promoted safe, person-centred care, learning and continuous improvement. Significant concerns relating to medicines management, safeguarding, healthcare escalation, record keeping and Mental Capacity Act compliance had not been identified through the provider's own systems despite information being available within incidents, records and family feedback.
Family feedback indicated that concerns were not always acted upon promptly and that confidence in management oversight was variable. One relative told us, "I think handover when going into the service could be better, no one seems to say anything unless I instigate it." Another relative reported, "They say someone will phone me back, but no one usually does phone back." A further relative described repeatedly raising concerns regarding agreed safety arrangements, stating they had needed to remind staff on several occasions because "not everybody follows it." These comments demonstrated that concerns identified by families were not always recognised and addressed proactively through the provider's own systems.
Although staff described the service as caring and supportive, and families frequently praised the commitment of frontline staff, the concerns identified during inspection demonstrated a disconnect between the provider's stated values and the effectiveness of governance arrangements. Significant quality and safety concerns remained unidentified through audits, incident analysis and management oversight, despite being evident within service records and the experiences of people and their relatives.
As a result, the provider could not demonstrate a culture that consistently promoted transparency, accountability, learning and continuous improvement, or one that effectively listened to and acted upon the experiences of people using the service and those important to them.
 

Leaders did not have effective oversight of the quality and safety of the service. Inspection identified significant concerns relating to medicines management, safeguarding, deteriorating health conditions, record keeping and governance that had not been recognised through existing management systems. Family feedback identified concerns regarding communication, continuity of care and inconsistency of support, indicating leaders did not always have a full understanding of people's experiences. Although senior leaders acted decisively following inspection by introducing additional oversight, external support and improvement plans, these actions were implemented in response to regulatory intervention rather than through the provider's own monitoring systems. The provider could not demonstrate leadership arrangements that consistently identified and responded to risk.

People, relatives and staff were generally able to raise concerns, but the provider could not always demonstrate that concerns resulted in timely action or sustained improvement. Family feedback identified occasions where issues had to be raised more than once before changes were made and where agreed actions were not followed through consistently. Concerns raised by families mirrored issues identified during inspection, reducing assurance that feedback was consistently reviewed and acted upon. However, relatives described staff as approachable, and staff spoke positively about management support. Whilst opportunities existed to raise concerns, the provider could not consistently demonstrate that feedback was translated into meaningful and lasting improvement. Staff told us they felt confident raising complaints, and there was a whistleblowing policy in place.

The provider did not always demonstrate that workforce arrangements promoted an inclusive, supported and well-developed workforce. Inspection identified gaps in supervision, competency assessments and oversight of staff performance. The provider could not consistently demonstrate that all staff had received regular supervision, appraisal and competency reviews, particularly in relation to medicines management and other specialist areas of practice. This reduced assurance that staff were being supported to develop the skills, confidence and knowledge required to meet the diverse needs of people using the service.
Inspection also identified weaknesses in workforce monitoring and governance. Significant concerns relating to medicines management, risk management and record keeping had not been identified through existing management oversight processes, reducing assurance that leaders understood the support and development needs of the workforce or the impact this may have on people's experiences and outcomes.
However, staff generally spoke positively about their experience of working at the service and described supportive relationships with managers. One staff member told us, "The management always listens to us." There was no evidence of discrimination or exclusion within the staff team, and staff described a positive and supportive working environment, where they complain and be heard.
Whilst there was evidence of a caring and supportive culture, the provider could not consistently demonstrate that workforce arrangements, development systems and management oversight were sufficiently robust to support all staff to perform their roles effectively and consistently.
 

The provider did not have effective governance systems to ensure the quality and safety of the service. Significant concerns relating to medicines, safeguarding, epilepsy management, healthcare escalation, record keeping and risk management were identifiable within incidents, records and family feedback but were not recognised through governance processes. Internal audits failed to identify significant concerns found during inspection, and incident analysis did not identify recurring themes despite repeated medication incidents, seizure activity and injury-related concerns. Families described issues being resolved only after intervention from relatives or external services. Although governance structures existed, they did not provide effective oversight or assurance that risks were identified and acted upon in a timely way. The provider held information demonstrating recurring medicines concerns, injury patterns, safeguarding issues and documentation failures. Despite this, governance systems did not effectively analyse or act upon that information, reducing assurance that risks would be identified and addressed before people were affected.

The provider did not always work effectively with families, healthcare professionals and partner organisations to ensure coordinated care. Inspection identified occasions where information was not consistently shared, acted upon or reflected in care planning arrangements. Family feedback highlighted examples where concerns identified by relatives or external services required intervention before action was taken and where communication between services was inconsistent. However, records showed staff worked with healthcare professionals when concerns were recognised and the provider engaged positively with commissioners and external partners following inspection. Whilst partnership working took place, the provider could not consistently demonstrate effective collaboration and information sharing across all services involved in people's care.

The provider did not consistently demonstrate a culture of learning and continuous improvement. Information relating to medicines management, safeguarding, epilepsy management, healthcare escalation and record keeping was available within incidents, records, audits and family feedback, yet opportunities to identify themes and implement sustainable improvements were repeatedly missed. Quality assurance systems did not consistently identify significant concerns later found during inspection. Family feedback also highlighted occasions where improvements occurred only after issues had been repeatedly raised or external services became involved. Although significant improvement actions were introduced following inspection, these were largely driven by regulatory intervention. Several concerns identified during this inspection reflected issues previously identified through audits, improvement plans, provider reviews and partner feedback. This demonstrated improvement activity was not consistently embedded or sustained. As a result, the provider could not evidence learning and improvement were sufficiently embedded to proactively improve outcomes and reduce risk.