Pine Lodge Care Home

Updated 24 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was completed by 2 inspectors, a specialist professional advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Pine Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Pine Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post. However, they did not take part in the inspection as they were on leave.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since they were registered. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people who lived at the service and 11 relatives about their experience of the care provided. We spoke with 9 staff including the operations manager, deputy manager, team leaders, care staff and chef. We spent time observing interactions between staff and people in communal areas. We reviewed a range of records including 14 people’s care records including medicines records. We looked at 6 staff recruitment records and a variety of records relating to the management of the service including meeting minutes and audits.

Updated 24 August 2023

About the service

Pine Lodge Care Home is a residential care home providing accommodation and personal care to up to 59 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 58 people using the service.

People’s experience of using this service and what we found

Although people and their relatives told us the service was safe and they were well cared for, we found risks to people had not been managed. The provider and registered manager lacked oversight and had not acted to understand the quality of the service and make improvements. They had not developed a culture where people received care personalised to their individual needs and their views and experiences were understood and used to develop the service.

Potential safeguarding concerns had not been shared with the local authority safeguarding team so they could be investigated. People’s medicines were not managed safely and they had not always received their medicines as prescribed. People were not offered food that met their health needs. Staff had not always shared sufficient information with health care professionals for people’s health needs to be understood.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People were not always treated with respect.

Any equality needs were not identified and understood. People had not been given the opportunity to discuss their end of life plans and wishes. Information was not accessible to people in ways they understood. People’s needs had not been assessed before they moved into the service. They had not been informed of the use of CCTV and their consent to its use had not been obtained.

Staff had not been recruited safely and received the training and support they needed to fulfil their roles. Records were not accurate or complete. Guidance had not been provided to staff about how to meet people’s individual needs. Lessons had not been learnt when things had gone wrong and people and their relatives had not always received an apology.

The environment had not been planned and decorated to support people to be as independent as possible. People were protected from the risk of infection.

Staff were kind and caring. People and their relatives were confident to raise any complaints with the management team.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 6 January 2022 and this is the first inspection. The last rating for the service under the previous provider was Good, published on 21 July 2017.

Why we inspected

The inspection was prompted in part due to concerns received about access to health care, diabetes management, inaccurate records, staff training and support, medicines management and ineffective checks and audits. A decision was made for us to inspect and examine those risks.

Enforcement and Recommendations

We have identified breaches in relation to staff recruitment and training, oversight and continuous improvement, records, obtaining and acting on feedback, mitigating risks in relation to people’s safety, medicines and diet, obtaining consent, assessments, privacy and treating people with dignity at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.