Pine Lodge Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were systems in place to record incidents, and staff knew how to do so. When incidents had been identified lessons had been learnt and shared with staff. Incidents and accidents were analysed for trends. Monthly group learning sessions had been introduced as well as reflective learning and the service had seen improvements. For example, lessons regarding falls had been learnt and improvements made such as ensuring there was always a staff member in the lounge to provide support to people.

Further work was needed to ensure good practice was embedded and practice was improved to develop a culture of safety. For example, following one incident a person had requested action was taken which impacted on fire safety. Whilst a risk assessment had been put in place the risks in the event of a fire had not been sufficiently mitigated against, and the person was left at increased risk of harm.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were systems in place to provide information to other services such as hospital staff when people moved between services. However, feedback from partner organisations was mixed. Mainly partners where happy referrals had been made in a timely manner and were appropriate. However, communication between the services own staff was raised as a concern and some health professionals felt staff could be better prepared for their visit. One partner organisation felt staff were knowledgeable about people’s needs and were able to provide good histories about people during their visit. However, one partner told us information was not always provided in advance which impacted on the continuity of care. Another partner organisation raised that the services’ documentation needed to be improved to enable them to understand the person’s needs better.

The provider worked with people to understand what being safe meant to them and the best way to achieve that. Staff understood how to identify safeguarding concerns and how to report these both internally and to the local authority where needed. One staff member told us, “I feel confident to report any concerns, wouldn’t hesitate.” The provider shared concerns quickly and appropriately. Concerns were raised with the local authority and shared with CQC as required. Action was taken following concerns. Staff also knew how to whistleblow if they were concerned about poor practice at the service.

However, as risks to people changed care plans were not always updated to reflect this change and provide staff with new guidance. For example, one person no longer needed one to one support to reduce the risk of incidents, and their care plan needed to be updated to reflect how staff should support them now risks were reduced but not eliminated and there remained the risk of a safeguarding concern occurring.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and met people’s needs.

People and their relatives told us they felt safe. However, we identified a number of areas where safety needed to be improved. The standard of care planning and support for people with their health needs was mixed. Where some people were supported with diabetes, their care needed to improve to ensure staff responded appropriately when people’s blood sugar was high. We raised this with the provider during the inspection and amendments were made to one person’s care plan. However, further improvement was needed. Training was provided to the chef, and reflective learning was provided to staff to seek to improve care provision going forward.

Care planning for people who were identified as pre-diabetic also needed to be improved to ensure staff knew how to support the person to reduce the risk of developing diabetes.

Support to people with constipation was also an area where improvement to was needed. For example, one person’s bowel movements had changed from regular to not regular and there was no evidence this had been identified and investigated to determine if the person needed further support. Care plans where people were at risk from constipation needed to be improved to ensure staff knew how to reduce the risk of constipation occurring and what to do if medicines did not lead to constipation improving. We raised this with the provider who arranged for staff to undertake further learning in supporting people with constipation.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Prior to the inspection there had not been a night time fire drill since October 2024 and the provider could not evidence, how they had assured themselves staff were able to support people to evacuate safely. The drill prior to this in August 2024 it was noted ‘the staff need to become more knowledgeable and confident on how to proceed’. We raised this with the provider who re-instated regular fire drills for staff. People’s evacuation plans needed to be reviewed as there was information about the support people needed missing such as how to support people who might be upset or distressed to leave the building safely.

Following the inspection we also received from negative feedback regarding the standard of wheelchairs and pressure relief cushions at the service.

During the inspection people were all using one lounge because there had been a leak in the roof which was being repaired. Other areas of the environment were well managed. For example, regular checks on utilities were completed.

Prior to the inspection the provider did not make sure there were enough qualified, skilled and experienced staff appropriately deployed at the service.

Feedback from people and relatives about staffing levels was not always positive. One person told us they sometimes had to wait an hour for the toilet. They said, “I could be waiting up to an hour. The night staff are better; they might be 10-15 minutes”. One relative told us, “Staff work really well, but there’s not enough staff”. Another relative said, “Some people get here [the lounge] at 11:30am and have breakfast, then it’s lunch at 12pm”. Concerns about staffing levels had also been raised by a number of professionals who visited the service. One health and social care professional told us, “If the resident asks to go to the toilet, they often have to wait a long time.”

We observed there were times people had to wait for support. For example, one person told the staff they were concerned about a health issue. Staff told the person they would have to wait for support with this. People were left waiting for breakfast.

We shared our concerns with the provider during the inspection and staff levels were increased as a result. The provider had used a dependency tool to support them to assess staffing levels. However, the processes in place had not led to there being enough staff to support people prior to the inspection and needed to be improved.

Care staff had completed the training they needed to provide support to people. One new chef needed to complete training in diabetes care, but this was completed during the inspection. However, there were areas where practice needed to be improved such as diabetes care and support with constipation. During the inspection we observed staff leading one person through the service whilst the staff member walked backwards. This was not good practice and increased the risk of an incident.

Staff received support and supervision and were recruited safely. Checks on staff prior to them working alone with people, had been completed.

The provider assessed the risk of infection. In the main they detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly. However, there were areas where improvement to cleanliness was needed where there were odours of urine. We found in there was furniture which had an including, but not limited to, the lounge. We raised this during the inspection and the concerns regarding odours were addressed. However, the identification and addressing of odours needed to be improved.

Staff had access to personal protective equipment (PPE) such as aprons and gloves, and we observed staff wore these. There were bins for staff to safely dispose PPE. The laundry used red bags to separate washing contaminated with bodily fluids to reduce the risk of infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There were areas where more information was needed regarding people’s medication. When people were prescribed ‘as and when’ medicines (PRN), guidance in place was not in line with best practice. For example, one person had a PRN medicine for constipation. There was no information for staff on when to refer a person back to the GP or nurse who prescribed the medicine, when a second dose could be given or what to do if the medicine had not had the desired outcome.

Staff wore tabards whilst administering medicines to let staff know not to disturb them. This helps reduce the risk of medicine errors. However, we observed staff were interrupted during administration by other staff and management. There were also times when they needed to help people or relatives.

Medicines were stored safely in a locked space which was temperature controlled. Where staff needed to follow enhanced procedures for some medicines these were followed.

Where people used pain patches there was no body map in place to ensure staff knew where to place these patches each week to reduce the risk of irritating the skin. However, this was addressed during the inspection. Medicines were disposed of safely in line with best practice guidance.