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 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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents, incidents and events were logged. The registered manager was informed of each incident and undertook reviews to identify trends. The registered manager had oversight and took action to prevent recurrence, lessons learnt were shared in team meetings, supervisions and where appropriate, with relatives. A relative told us, “I know things aren’t perfect all the time anywhere, but for a long time now it’s been getting better at The Pines, and I trust the registered manager, they would contact me if there was something I needed to know.”

The provider explained how they learn from adverse events across all their locations and the wider social care sector to improve the standard of care for people living at The Pines. Leaders told us, “Where appropriate, learning and examples of good practice will also be shared externally with partner organisations and professionals, supporting sector-wide improvement and ensuring people we support benefit from the latest evidence-based approaches and best practice.”
 

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People and their relatives told us the service communicated well with other services to ensure people’s needs were known.

Staff knew where to access information about people and kept up to date with any changes to their care, following new guidance from external professionals or after a hospital stay. Communication between the service and external professionals was established and operating well, feedback collected from all professionals during the inspection was positive.
 

The service 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.

People told us they felt safe. Staff understood how to raise concerns and were confident the management of the service would act immediately if they had to raise their concerns with them. Staff knew of external agencies such as the police and local authority safeguarding team who they could contact in the event the concerns were not acted upon. The provider told us, “Designated Safeguarding Champions help to provide ongoing support to staff through coaching, reflective practice and shared learning opportunities.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The registered manager had oversight of authorisations, and this meant people’s rights were fully respected.
 

The service 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 take positive risks and do the things that mattered to them.

People told us staff worked to keep them safe and understood their needs, this had enabled people to improve their lives. Relatives informed us they had confidence their loved ones were always supported to move freely around the service.

Staff knew people well and told us they had enough information regarding people’s individual risks. A staff member said, “We have access to detailed care plans and risk assessments, which are reviewed and updated regularly. Information is shared during verbal handovers, through the electronic system and in the communication book. This provides staff with the information needed to support people safely and consistently.”

The provider told us, “Risk management focuses on what people can achieve rather than what may prevent them from reaching their goals. Staff are confident in balancing safety, choice and positive risk taking.” This was echoed by feedback from a visiting health and social care professional who said, “People are encouraged to be independent where possible such as in the kitchen and with personal care. Everyone is treated with respect during my visits.”
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us they felt safe, and their risks were considered. People confirmed they felt involved in planning for their needs in relation to risks and keeping safe.

Staff told us about daily tasks completed to keep people safe. These included regular visual checks of the property, reporting any concerns identified to the provider so these could be rectified. Health and safety audits ensured maintenance of equipment took place as required and any areas for action were addressed.
 

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us staff were there when they needed them. Training was available in accordance with good practice guidelines for staff who worked with people who required care and support. The provider highlighted the importance in developing their workforce. Comments included, “Professional development is aligned to organisational objectives and informed by research and best practice”, and “We will ensure staff have the skills, knowledge and confidence to meet the changing needs of people we support whilst contributing to succession planning, service sustainability and continuous improvement across The Pines and the wider organisation.”

Recruitment processes were in place; staff were recruited safely. Procedures were in place to ensure the required checks were completed prior to staff commencing their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.
 

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 supported people to maintain their home environment. Where possible, people using the service were empowered to participate in activities to keep the service clean. A person told us everything they have learnt about infection control and said, “It’s my job here, make sure it’s clean and staff know the colours of the mops and cutting boards.”

Leaders shared their commitment to ensure infection prevention was embedded within everyday practice and formed part of the service's wider commitment to promoting health, wellbeing and quality of life. Staff confirmed they had access to personal protective equipment, had received training in infection control and followed the provider’s policy.
 

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

There were safe processes in place for ordering, storage, administration and disposal of medicines. Staff who were responsible for giving people medicines were trained. We observed medicines were stored at safe temperatures and checks were in place to ensure this was maintained. Guidance supported staff to ensure medicines taken occasionally were given in a consistent way. Medicines which required stricter controls were monitored and correct control measures were in place.

The registered manager and staff welcomed input from health and social care professionals to review the medicines of people using the service, in line with the principles of STOMP (Stopping the over medication of people with a learning disability, autism or both). The registered manager said, “We requested a STOMP review of a person’s medicine as no one was sure why they had been on a high dose of this medicine for such a long time. We noticed the person seemed to have a high number of falls. After ruling out other health possibilities, the medicine was reduced and we saw less falls occurring and their mobility improve.” This meant the commitment to people’s best interests and professional curiosity had a positive impact on people.