The Pines

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 requires improvement. This meant some aspects of the service were not always safe, and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.
 

This service scored 44 (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 effective oversight of incidents.

We found no evidence that themes or trends were monitored to reduce the likelihood of incidents recurring. We also identified several incidents that met the threshold for statutory notification to CQC but had not been reported. We highlighted these specific incidents to the management team during the assessment.

However, the provider did maintain an incident log and used Antecedent Behaviour Consequence (ABC) charts to record incidents and accidents. ABC charts documented changes in behaviour, possible triggers and actions taken. The provider told us incidents and accidents were discussed during handover, and in the sample of incident forms we reviewed, most included actions taken, follow up steps and a brief learning summary, such as staff debriefs and reviews of care records to reinforce preventative strategies.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care where safety was monitored and managed effectively. They ensured continuity of care, including when people moved between services.

The provider described the systems and processes they used to assess people’s needs, suitability and compatibility when moving into the service. They worked closely with community nurses to ensure people’s complex needs could be met from the outset. We saw evidence of communication with healthcare professionals, including the community paramedic and consultants, to discuss and review people’s ongoing needs.
 

The service did not always work effectively with people or with healthcare partners to understand what being safe meant to them or how to support this in practice. Staff did not consistently prioritise improving people’s lives or upholding their right to live free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were not always shared promptly or appropriately.

We identified several incidents where safeguarding referrals had not been made. For example, there were altercations between people living in the service. These included situations where tea was thrown at individuals and incidents where people attempted to physically harm others. The provider was unable to demonstrate that all such incidents had been reported to the local authority safeguarding team, in line with statutory requirements. This meant the service could not evidence that risks had been fully recognised, escalated or acted upon.

In relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), the provider had previously been in breach of regulations concerning consent. At this assessment, improvements had been made, and the provider was no longer in breach. The service now had systems in place to monitor authorised and pending DoLS applications. A DoLS tracker showed which applications had been approved and which were awaiting a decision from the relevant local authority.

The lack of consistent safeguarding referrals placed people at ongoing risk of abuse and avoidable harm. Failure to notify external safeguarding bodies reduced the opportunity for independent oversight and prevented timely intervention to protect people. Incidents between individuals could escalate without appropriate action, leaving people vulnerable.

Although improvements had been made to DoLS processes, the inconsistent approach to safeguarding limited the provider’s ability to ensure people were consistently protected from harm and supported to live safely.
 

The provider did not always work effectively with people to understand, assess and manage risks to their safety. Staff did not consistently provide care that was safe, supportive or aligned with people’s assessed needs and preferences.

Although the provider told us they did not use restraint, we found an incident where a person had been physically restrained by staff. This person had a Positive Behaviour Support (PBS) plan, which is a structured approach used to support individuals, including those with learning disabilities or autism, to reduce distress and behaviours of concern. However, the person’s PBS plan did not authorise or advise the use of restraint. This meant staff actions were not in line with the person’s assessed needs or agreed support approach.

We also reviewed another person’s mental capacity assessment, which suggested staff may need to use restraint in certain circumstances. However, their care plan did not specify that restraint was an approved intervention. The provider was also unable to demonstrate that staff had received the correct training to use restraint lawfully, proportionately, and only as a last resort. This created a risk staff could use restrictive practices in an inconsistent or unsafe way.

Additionally, one person required rescue medicine in the event of an epileptic seizure. The provider could not evidence that staff had received appropriate training or competency checks to administer this safely. While the provider showed us that relevant training had been scheduled following the assessment, this had not yet been completed at the time of inspection.

The provider had completed some risk assessments and detailed care plans. However, they had not ensured people’s environments were consistently maintained or monitored to keep them safe. They had also not completed required risk assessments for people using flammable creams, despite the known fire risks associated with these products.

These failures placed people at risk of unsafe care, inconsistent support and inappropriate use of restrictive practices. Without clear guidance and trained staff, people were at increased risk of avoidable harm, including injury, distress or unsafe responses during incidents. Missing environmental safety checks and the absence of risk assessments for flammable creams further exposed people to preventable hazards.
 

The provider did not always identify, monitor or control environmental risks. They did not ensure that equipment, facilities and safety processes consistently supported the delivery of safe care.

We found the provider had not completed regular water temperature testing to ensure temperatures remained safe for people using the service. There was also no evidence that infrequently used water outlets were being routinely flushed, meaning risks associated with legionella were not being monitored or mitigated. We discussed these concerns with the provider at the time of the assessment.
Premises and equipment safety audits had been completed; however, these checks had not identified the concerns we found. During our visit, we saw multiple extension leads in use in people’s rooms, creating potential trip hazards and increasing the risk of fire. The provider informed us after the assessment that they had taken action to address this with the support of an electrician.

Each person had a personal emergency evacuation plan (PEEP), and staff completed fire drills twice a year. While this demonstrated some planning for emergencies, it did not mitigate the environmental risks identified during the assessment.

The lack of routine water monitoring, legionella controls and oversight of environmental hazards exposed people to avoidable risks of harm, including scalding, infection, trips or fire. Failures to identify concerns through routine audits meant risks could remain unaddressed, reducing the provider’s ability to ensure a consistently safe environment.
 

The provider did not ensure there were enough suitably qualified, skilled and experienced staff to meet people’s needs safely. Staff were not consistently trained or assessed as competent to carry out the tasks required of them. Recruitment processes were not robust, meaning people were cared for by staff whose suitability had not been fully established.

The provider could not demonstrate that staff had been assessed as competent in essential areas of practice before supporting people. We found no recent competency assessments for catheter care, administration of epilepsy rescue medicine, or moving and handling. Despite this, staff were actively carrying out high risk procedures such as changing stoma catheter bags without evidence of training or competency. This meant people were being supported by staff who were not proven to have the required skills.

We also found the provider could not evidence that the individuals responsible for signing off staff competencies had themselves been assessed as competent in the tasks they were authorising. This significantly reduced the reliability of competency assessments and increased the likelihood staff were being wrongly deemed safe to carry out clinical tasks.

When reviewing the staff training matrix, we identified significant gaps. Only two staff had completed training in ‘challenging behaviour’, despite people in the service requiring this support. Only one member of staff out of eleven had completed training in stoma care. This indicated there were not enough trained and competent staff available to safely meet people’s high risk needs.

Recruitment processes were also not robust. A sample of staff files showed unexplained gaps in employment history which had not been explored or verified before staff were appointed. Although the provider acted to address this after the assessment, information required under Schedule 3 of the Health and Social Care Act 2008 must be confirmed before employment begins.

These failures exposed people to a significant and ongoing risk of avoidable harm. Staff carried out complex clinical tasks without having been trained or assessed as competent, increasing the likelihood of injury, incorrect procedures or delayed emergency responses. Inadequate oversight of competency assessors further undermined the safety of care. Training gaps meant the provider could not ensure there were enough skilled staff available to meet people’s needs. Weak recruitment processes meant people were supported by staff whose safety, suitability and experience had not been assured, placing them at further risk.
 

The provider did not always assess, monitor or manage the risk of infection effectively. They did not consistently identify or control factors that could increase the likelihood of infection spreading within the service.

The provider’s infection prevention and control (IPC) audits were not effective. These checks had not identified several concerns we found during the assessment. We reviewed training records and saw some staff had not completed IPC training for up to seven years, meaning they did not have up to date knowledge of safe infection control practices.

We also observed that people did not always have access to their own hand soap. This meant they were not consistently supported to maintain good hand hygiene, which is essential for preventing the spread of infection.

We saw staff preparing food were wearing appropriate personal protective equipment (PPE). Staff told us, “We get assigned to do the cleaning. The carers are doing the cleaning but there is also a cleaner who does the cleaning.”

Ineffective audits, outdated staff training and a lack of basic hygiene resources increased the risk of infection spreading within the service. These gaps meant the provider could not be assured that staff were following safe IPC practices or that people were protected from avoidable harm.

The provider told us they frequently discussed IPC during supervisions and staff meetings.

The provider did not always ensure that medicines were managed safely or in line with people’s needs, capacities or preferences. People were not consistently involved in planning or reviewing how their medicines were used.

We found one person had been prescribed an ‘as needed’ (PRN) antipsychotic medicine to be used only during episodes of distress. However, this medicine was being administered twice daily, every day. The person’s care records did not demonstrate why this medicine was being given regularly or how its use had been considered as the least restrictive and last resort option. We raised this with the provider, who contacted the GP to review the prescription.

Another person’s vitamin D medicine was prescribed to be given weekly, yet it was being administered daily. This meant staff were not following the prescription, and medicines had not been checked or managed appropriately when received from the pharmacy.

PRN protocols were in place for most medicines; however, we found gaps in some protocols, including one for Lorazepam which was missing. Where protocols were in place, they lacked personalised information such as how individuals express pain or distress according to their communication style.

These failings increased the risk of people receiving medicines inappropriately or unsafely. Incorrect administration, missing protocols and lack of personalised guidance meant staff did not have the information needed to use medicines safely, proportionately or in line with professional standards. This exposed people to avoidable harm and reduced the provider’s ability to ensure safe, person centred medicines management.