Updated 15 July 2025
Date of inspection: This assessment took place between 15 July 2025 and 18 August 2025. We visited the service on 15 July and 21 July 2025. We found 4 breaches of the regulations in relation to safe care and treatment, dignity and respect, staffing and good governance. The service was rated required improvement but has now changed to inadequate.
Pine Lodge Care Home provides support to older people, some of whom live with dementia. The service is provided across two purpose-built buildings. The service can support up to 59 people.
There were systems and processes in place to manage incidents. However, not all actions taken as a result of incidents had considered wider risks when actions were taken. Some improvements had been made to management of other risks such as the risk of falls, for example by ensuring a staff member remained in the lounge to support people.
There were systems in place to share information when people moved between services. However, these had not always worked effectively. Staff knew how to identify the signs of abuse and how to report concerns. Concerns were reported. However, people’s care plans were not always kept up to date when the risk of safeguarding incidents occurred.
Care plans needed to be improved in some areas, and we were not assured risks to people from diabetes and constipation had been managed safely. We raised these concerns with the provider during the inspection and staff were provided with learning to improve how people were supported.
There were not enough staff to provide people with effective support. We raised this with the provider during the inspection and staffing levels were increased after the site visit.
Fire safety had not always been well managed prior to the inspection. There was a system in place to undertake monthly fire drills. However, the last nighttime drill had been the previous October and the provider had not assured themselves they had enough staff and equipment to evacuate people safely. This was resolved immediately after the inspection. Risks to people from utilities such as gas leaks had been mitigated.
Staff received support and supervision and were recruited safely. Staff had received training to support them in their role. However, there were areas of practice where improvement was needed.
The service was clean, but not always free from odour and this needed to be improved. Staff had access to PPE such as gloves and aprons and wore these appropriately. There were some areas where some medicine administration needed to be improved. For example, prior to the inspection the blood sugar monitor had not been calibrated. This was addressed during the inspection.
The management of the service needed to be improved. There was no registered manager at the time of the inspection and the service had not been consistently well managed. However, a new manager had been appointed and was about to commence in post.
People, relatives and staff had all raised concerns over staffing levels; however, sufficient action had not been taken to address the concerns raised. There was a system in place to record low level complaints however, more work was needed to ensure this system was consistently capturing people’s concerns and addressing them.
Governance systems needed to be improved to drive forward the quality and safety of the service. Record keeping needed to be improved. Partnership working needed to be improved to ensure people’s support was seamless and that the service was working together effectively with other organisations.
The provider valued diversity in the workforce and provided support to workers.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.’
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.