Pinetree 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 the last inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. We found the quality and safety team, clinical leadership teams and management team within the service constantly reviewed the operation of the service and actively made changes as and when these were needed.

Following a review by the provider’s health and safety team the incident monitoring records had been developed to give greater scope of information. The changes allowed more flexibility for staff to understand themes, reasons for the events and lessons, which could be learned. The changes to the way they monitored services meant they could readily identify even minor changes in practice and use the information to complete deep dives into the service. This had led to a wide range of improvements, including staff actively supporting people with their oral health and an increase in individuals accessing dentistry services. Staff were encouraged to share lessons from incidents and near misses, and these were discussed in themed supervision sessions.

Learning was cascaded across the service and shared with other locations operated by the provider. Staff told us they felt able to speak up and that their ideas were listened to, while managers were proactive in reviewing systems and introducing new tools to support understanding of risk and outcomes. This culture encouraged openness, reflection and a “no blame” approach that supported staff confidence.

Systems were in place to ensure safe care pathways and transitions. Risk assessments were comprehensive and regularly reviewed, enabling staff to manage presenting risks effectively. Staff worked collaboratively with healthcare professionals to respond promptly to changes in people’s conditions. People experienced safe and well-managed transitions between services. Care records were person-centred and supported continuity of care. Relatives generally felt informed. One relative told us, “When [person] has required it, I have found the staff to be proactive with medical intervention contacting the relevant medical professionals immediately when they are needed and ensuring that we are quickly informed of any concerns no matter how small.” Staff completed comprehensive assessments and shared the techniques and approaches which effectively supported people to reduce their level of distress with those providing care when the person moved on.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. When incidents occurred staff completed a full investigation and took a proportionate, balanced approach when dealing with them. Staff had training and a good understanding of what to do to make sure people were protected from harm or abuse. Records showed safeguarding incidents were investigated and lessons learned were shared with the team. Staff understood when Deprivation of Liberty Safeguards (DoLS) authorisations would need to be sought and what to do if there were conditions imposed. Some people were subject to the powers of Mental Health Act 1983 (amended 2007) and staff had a good understanding of how to ensure these requirements were met.

Staff worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were in place and assisted staff to identify how to mitigate risks. People’s individual risks were assessed and reviewed through multidisciplinary input, and relatives were often involved in shaping these assessments. Staff reported that “a lot of people are involved with care plans and risk management, including nurses, staff, family members.”

The provider detected and controlled potential risks in the care environment. The provider had a rolling programme of refurbishment. People were supported to be as independent as possible within the environment. Environmental risks were assessed and addressed. They made sure equipment, facilities and technology supported the delivery of safe care and worked with external professionals to review people’s aids. The staff team knew who to contact when people might benefit from additional aids or equipment. Staff were trained to use any equipment people needed.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. During the day a minimum of 10-11 care staff were on duty and shifts were split into morning and afternoon, with a 4 hour crossover period. They worked together well to provide safe care that met people’s individual needs. We found the reliance on care staff to complete laundry tasks throughout the week, work in the kitchen at tea-time and at the weekend impacted staffing levels. Albeit there is a marked period of overlap of staff from 11.30am to 4pm this meant key tasks such as dealing with the laundry would be problematic if left to this condensed time-period. A staff member said, “There is enough to complete things if the staff aren't having to go into laundry or in the kitchen on a weekend, as we lose a member of staff off the floor to cover these but we always get told we have the afternoon shift in. It would be better if the staff can solely concentrate on the residents.” The provider was reviewing how staff deployment during peak pressures such as on a morning, during medicine rounds and when meals were being prepared could be managed differently.

Recruitment practices were meeting requirements. The people’s team had developed robust training programme, which was effectively delivered, and they consistently evaluated its effectiveness. The team considered the impact this training had on how staff delivered the service and whether it was embedded into their practices. They consistently looked to see it assisted staff to effectively support people to improve their mental health and supported the organisation to embed the overriding culture of ‘Here so no one struggles alone.’ The provider offered access to additional training including access to nurse training, apprenticeships, preceptorship and mentoring programmes. A staff member said, “I feel there is enough training provided, we do online training before we are allowed on the floor, then we have Challenging Behaviour training, then when that is complete we will be paired up with someone who has worked with the company for a while someone who is experienced they will show them the daily tasks we do, these are called shadow shifts and you do these for two weeks or longer if more support is needed.”

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed the required infection control guidelines. Audits confirmed high compliance with hand hygiene and personal protective equipment (PPE) protocols. However there was a strong and persistent malodour evident throughout the home, and cleaning contractors were not consistently attending as scheduled. Staff reported that contractors used products that masked smells rather than addressing underlying causes. These issues indicated that infection prevention systems were not always implemented effectively and that oversight required strengthening to ensure a consistently hygienic environment. The provider was aware of these issues and was actively resolving them with the contract cleaning company.

Staff made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff who administered medicines had the appropriate training and competency checks. Storage areas were secure, and temperature checks were recorded. MAR charts were accurate, and controlled drugs were handled in line with regulations. The provider identified medication audits needed to be strengthened, and these supported staff to more readily identify gaps. Action plans were implemented to address any issues, and staff were routinely reminded of best practice. These practices ensured staff managed medicines safely.