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Pinewood Nursing Home Requires improvement

We are carrying out a review of quality at Pinewood Nursing Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 21 February 2019

We carried out an unannounced comprehensive inspection on 14 and 15 January 2019.

Pinewood Nursing Home is a care home with nursing for up to 30 people. On the day of our inspection there were 27 people living at the service. It specialises in care for older people who are living with dementia or have a physical disability.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Some of the people who lived in the home had limited communication therefore we spent time observing people.

At the last inspection, on the 27 June 2018 the service was rated Good overall. However, it has now been rated now Requires Improvement in Safe and Well Led. This was due to medicines not always being managed safely and the monitoring of medicines not being enough to reduce errors.

People’s medicines were not always managed safely or properly. People did not always receive their medicines as they should, including pain relief medicines. Some medicines were given and not signed for while others were not given but signed for.

We had received a concern in June 2018 in relation to medicines management. As a result, we asked the registered manager to send us the outcomes of their monthly medicines audits. These showed that the medicines management had not consistently improved in the service. On the day of our inspection we found six errors had already occurred in the last 12 days (3rd January to 14th January 2019). Action taken when audits had highlighted errors had not been robust enough to sustain good practice.

People lived in a service which had been designed and adapted to meet their needs. The provider monitored the service to help ensure its ongoing quality and safety. The provider’s governance framework, helped monitor the management and leadership of the service. The provider had monitoring systems which enabled them to identify good practices and areas of improvement.

However, though audits were carried out, medicines audits showed a high number of medicine errors including people not receiving their medicines as prescribed. Actions they had taken to improve practice had not been successful and medicines errors were found to have continued.

The registered provider took further action during the inspection. This included again writing to all staff to arrange additional in-depth medicines training and a letter outlining the issues we found.

Staff had completed safeguarding training and updates were provided. Staff had a good knowledge of what constituted abuse and how to report any concerns. Staff understood what action they would take to protect people against harm and were confident any incidents or allegations would be fully investigated. Staff confirmed they’d have no hesitation reporting any issues to the registered manager or provider.

People were protected by safe recruitment procedures. This helped to ensure staff employed were suitable to work with vulnerable people. Staff confirmed there were sufficient staff to meet people’s needs. Staff had completed appropriate training and had the right skills and knowledge to meet people’s needs. Staff also completed an induction programme when they started and their competency was assessed. Staff were provided training appropriate to the people they cared for, for example dementia care. Staff also completed formal care qualifications which included equality and diversity training.

People’s risks were assessed, monitored and managed

Inspection areas


Requires improvement

Updated 21 February 2019

The service was not always safe.

People did not always receive their medicines safely.

People agreed they felt safe.

People were supported by sufficient numbers of suitable and experienced staff.

Staff had a good understanding of how to recognise and report signs of abuse.

Risks had been identified and managed appropriately. Risk assessments had been completed to protect people.

People lived in a clean and hygienic environment that had been updated to a high standard.



Updated 21 February 2019

The service remains good.



Updated 21 February 2019

The service remains good.



Updated 21 February 2019

The service remains good.


Requires improvement

Updated 21 February 2019

The service was not always well led.

There were systems in place to monitor the safety and quality of the service. However, action taken following regular audits had not ensured people received their medicines as required.

There was an experienced registered manager in post who was approachable.

Staff were supported by the registered manager and there was open communication within the staff team and staff felt comfortable raising and discussing any concerns with them.

People�s views on the service were sought and quality assurance systems ensured improvements were identified and addressed.