The Pines

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 remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance and notification of other incidents.
 

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding of people's challenges and needs and their communities' needs.

We found that staff meetings were held regularly. The minutes demonstrated that different topics were discussed throughout, including people’s activities, supporting infection prevention and control and delivering person-centred care.

Staff told us, “The service has good values, because of the way they treat the residents. It is a place I recommend bringing their relatives in the care home. We have good training about everything. I truly recommend it to people.”
 

Not all leaders understood the context in which the provider delivered care, treatment and support. Governance processes were not always effective in ensuring regulatory responsibilities were met.

Staff meetings were held regularly, and minutes showed a range of topics were discussed, including activities, infection prevention and control and person centred care. The manager told us they encouraged staff development, and staff described feeling supported. Staff said the provider had good values and that they would recommend the service. The provider also planned to assign team leaders to each shift and intended to introduce a monthly magazine to promote achievements.

Although most accidents and incidents were documented, measures to prevent further occurrences and lessons learned were not always recorded. We also found incidents that should have been notified to CQC but had not been submitted. When we discussed these with the provider during our assessment, they were unable to demonstrate a clear understanding of their regulatory notification responsibilities. The provider retrospectively submitted the required notifications following our visit.

The lack of governance oversight and incomplete incident analysis placed people at avoidable risk of repeated accidents and missed opportunities to learn and improve. Failure to submit required notifications also meant the provider was not consistently meeting its legal obligations for regulatory oversight.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider told us, “[Staff] speak [up] everything. Even when I do something wrong. They have their voices, and we have a whistleblowing policy and things like that. They say it sometimes straight away on a handover. They will report it. They are knowledgeable. So far, they have not done it. They will always come to the office and say if something is not right.”

Staff told us they felt able to speak up. One person said, “Leaders encourage us to speak up during the monthly staff meetings where they encourage us to raise our concerns and make suggestions to improve things. We also have a suggestions box where we can put in suggestions anonymously. I feel like I have the right platform to speak up.”
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider told us staff were aware of equality and diversity policies, and the manager told us, “We feel we work in a team all the time .”

A staff member told us, “They all welcomed me here when I came. I am very happy. Everything is fine, I don’t have anything to report. I really got good support from the staff, which motivated me to work harder.”
 

The provider lacked clear responsibilities, roles, systems of accountability, and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s quality assurance systems did not identify concerns we found during this assessment, which are described throughout this report. The provider did not have oversight of the quality of care being provided, risk management and mitigation, staff practices, knowledge and competency to support people.

The registered manager did not monitor recruitment checks were carried out to ensure all required information was gathered to ensure there were suitable staff to work with people. We found staff were not adequately trained and competent prior to providing care and treatment.
Although the provider maintained an incident log and recorded reviews of each incident, there was no evidence that the provider proactively looked at trends or themes in the incidents, accidents and complaints that occurred so that they were able to identify areas of concern and take action to prevent recurrence and safeguard people.

The provider did not ensure management of medicine was safe and proper including checks for medicine competencies. This meant they were unable to demonstrate how they identified and addressed areas that needed improvement.

Systems did not always ensure incidents were reported to the local authority and/or CQC, which was not in line with the provider’s regulatory responsibilities. The provider failed to ensure CQC were notified without delay of several statutory notifiable incidents. These included incidents resulting in injuries that, in the opinion of a healthcare professional, caused changes to the structure of a service user’s body; any abuse or allegation of abuse relating to a service user; and Deprivation of Liberty Safeguard applications.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider told us how they worked with various agencies, including hospitals, pharmacies and community teams, to support people and their individual needs. The provider demonstrated examples of this effective working with district nurses when they supported one person who had sustained burns to recover from their sustained injuries.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation or local system. They did not consistently encourage creative approaches that promoted equality of experience, outcomes or quality of life. Opportunities to learn from practice and contribute to safe, effective care were not always taken.

The provider told us they had introduced new ways of monitoring seizure activity, using graphical tracking which was shared with hospital consultants during clinical reviews. This demonstrated some commitment to improving practice in specific areas.

However, the provider did not demonstrate learning from other critical sources of information, such as incident records and Antecedent, Behaviour and Consequence (ABC) charts. This meant patterns of distress, triggers and appropriate responses were not always identified or acted upon. We also found that the provider and GP changed one person’s medicine used during distress without linking this decision to daily notes or their ABC chart information, meaning decision making was not always informed by the available data.

These gaps meant effective practice was not always implemented. Failing to analyse behavioural patterns or learn from incidents placed people at risk of receiving inconsistent or poorly informed care and limited the provider’s ability to improve outcomes or reduce distress.