The Care Quality Commission
  • Care Home
  • Care home

Pine Lodge Care Home

Overall: Inadequate read more about inspection ratings

26-32, Key Street, Sittingbourne, ME10 1YU

Provided and run by:
Eleanor Nursing and Social Care Limited

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

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.

During an assessment under our new approach

Date of Assessment 26 March to 19 April 2024.

Pine Lodge is a residential care home providing personal care to older people. This assessment was completed to check improvements had been made since our last inspection.

We assessed a total of 23 quality statements from the safe, effective, caring, responsive and well led key questions and found areas of good practice. The scores for these areas have been combined with scores based on the key question ratings from the last inspection. Though the assessment of the quality statements indicated areas of good practice since the last inspection, our overall rating is requires improvement.

We found there had been improvements in the management in all areas of the service. There was now clear guidance for staff to manage potential risks to people’s health and welfare. There was now a process in place to learn from accidents and incidents to reduce the risk of them happening again. There were now processes in place to protect people from discrimination and abuse.

Staff were now recruited safely and there were enough staff to support people safely, they received training and supervision. Staff now understood their responsibility under the Mental Capacity Act 2005 and people were supported to make decisions. There were now processes in place to manage infection control and the administration of medicines. People were now supported to access health professionals and live healthier lives.

People’s privacy and dignity was maintained, people received information in a way they could understand. People were now supported in a person centred way and were now involved in the service.

11 July 2023

During a routine inspection

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.