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Pinehurst Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 28 June 2019

About the service:

Pinehurst Care Home is a ‘care home’ without nursing and is registered to provide accommodation and support for 23 people. At the time of our inspection, there were 21 people living at the service. People living at Pinehurst were older people, some of whom were living with dementia.

People’s experience of using this service:

Risk assessments had not been carried in relation to people’s individual needs and the environment in general. Equipment was not always checked and ensured it was working correctly.

The service did not comply with the Mental Capacity Act 2005 and mental capacity assessments had not been undertaken. For those people being restricted in their lives at Pinehurst, Deprivation of Liberty Safeguards had not all been applied for.

There was a lack of oversight of the service. Regular monitoring of the service had not been carried out to identify any improvements that were needed. There was a lack of service user involvement with people’s views of the service not recently requested.

Systems of governance and oversight were not sufficiently robust to have identified the issues we found in relation to practices, systems and record keeping at the service.

The building needed repair, redecoration and refurbishment in some areas to ensure people were able to live in a safe and comfortable home.

Staff were safely recruited and undertook training to do their jobs properly. Staff did not always receive regular supervision.

There were adequate staff to meet people’s needs. People spoke positively about the staff and said they were kind and caring. Positive relationships had been built between staff and people and their families. People were treated in a non-discriminatory way and encouraged to maintain their independence.

The service worked with local healthcare professionals when required and support people to remain at Pinehurst at the end of their lives.

People enjoyed the food they ate at Pinehurst and received their medicines safely. Activities took place, but these were not always related to people’s individual interests and hobbies.

The registered manager was visible at the service and encouraged an open atmosphere. They were respected by staff. They were aware of the service failings from this inspection and were motivated, passionate and keen to improve the service for people to enjoy living in.

More information is in the full report.

We identified three breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to safe care and treatment, the need for consent and good governance; one breach of the Care Quality Commission (Registration) Regulations 2009 relating to failing to provide notifiable incidents, and one recommendation about improving activities for people living with dementia.

Rating at last inspection:

At the last inspection, the service was rated Good in all areas and as an overall rating (23 September 2016).

Why we inspected:

This was a planned comprehensive inspection based on the last report rating.

Follow up:

We have asked the provider to send us an action plan telling us what steps they are to take to make the improvement needed and meet the breaches of regulation. We will continue to monitor the intelligence we receive about the service. We will return to re-inspect in line with our inspection timescales for Requires Improvement services. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 28 June 2019

The service was not always Safe.

Details are in our Safe findings below.


Requires improvement

Updated 28 June 2019

The service was not always Effective.

Details are in our Effective findings below.



Updated 28 June 2019

The service was caring.

Details are in our Caring findings below.


Requires improvement

Updated 28 June 2019

The service was not always Responsive.

Details are in our Responsive findings below.


Requires improvement

Updated 28 June 2019

The service was not always well-led.

Details are in our Well-Led findings below.