Pine Lodge Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture which was clearly shared with staff. The provider wanted to move towards providing outstanding care. However, there needed to be more focus on the underlying basics to provide a good foundation to build on. For example, ensuring there were enough staff and good care plans. This had impacted on the standard of care people had received and the delivery of the provider’s vision.

The provider had been working to improve the overall culture within the service. However, there was still improvement needed to build an effective management and staff relationship. For example, during the team meeting prior to the inspection staff had been told they needed to ‘work on moving away from this “lack of staff” culture’ when there had been real concerns about staffing.

Leadership at the service had not been consistent as there had been a number of staff changes. At the time of the inspection there was no registered manager in place and there had not been since February 2024. Feedback about management was mixed. One relative said, “[My relative] has been here one year, the turnover of management is a shame”. One partner told us, “There has been at least 5 managers in the last 3 years, some have been approachable” and then they gave us an example of how one manager was not approachable. However, a new manager had been recruited and was due to commence in post shortly after the inspection.

A regional manager was acting as the service manager at the time of the inspection. They were supported by a deputy manager, three other regional managers, a compliance manager and the nominated individual. The acting manager was experienced in their role and understood the duties expected of them but was fairly new to the service so had had limited time to make improvements.

People’s voices were not always heard as well as they could have been. There were missed opportunities to listen and improve. Some staff told us they felt listened to but there were areas where they had not been.

People, relatives and staff had raised concerns about staffing levels prior to the inspection.

Comments from a survey of people and relatives also raised concerns. Comments included, ‘I feel that some staff are too busy and just want to get away, rather than help or discuss for little time.’, ‘Sometimes staff are too busy’ And, ‘There is a long wait’ [regarding meals].

Comments from a in a recent staff survey included, ‘Not enough staff per shift to meet residents’ high needs’ And, ‘when we don’t have enough staff it is difficult to be able to get our jobs done. sometimes it can feel that you are not giving the residents enough support that they need, and they should deserve.’ Staff also raised concerns at team meetings, which were initially dismissed as ‘a perception of low staffing’. However, the provider did reflect on the feedback provided during the inspection and following our visit made changes to the number of staff planned to be on shift.

There was a system in place to record low level complaints (grumbles). However, there was only one comment recorded, which was a complaint about staffing levels. People and their relatives told us they had raised other issues. However, these had not been captured. This meant there was a missed opportunity to ensure minor complaints were responded to and to analyse any themes or trends.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they were supported to celebrate religious occasions such as Eid. Staff feedback was positive, one staff told us, “I feel seen now, we shared what Eid was with the staff and residents. It was empowering.”

Where staff had needed reasonable adjustments put in place to support them to continue in their role these had been so. Staff were also encouraged to join in or hold cultural events such as eating foods from other world cultures together to promote learning and create connections.

The provider did not have effective systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Quality assurance systems had not always identified and addressed areas of concern. For example, auditing did not identify concerns relating to the monitoring of people’s blood sugar levels and how staff had responded. Systems had not identified where people had constipation or were at risk their care plans needed more information. Auditing of medicines had not identified ‘as and when’ medicine protocols were incomplete and needed more information.

The systems in place were not effective at always driving forward improvement and ensuring overall safety. For example, systems had not led to consistent staffing levels, and we observed one person waited 45 minutes for breakfast. They told us, “I often have to wait, but it’s nice when it finally comes”.

Governance systems had not ensured the service had maintained accurate, complete and contemporaneous records. There were long gaps in some people’s daily notes where no activity had been recorded to demonstrate people were being effectively supported throughout the day.

The provider did not always ensure partnership working was effective to ensure services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Feedback from partners was mixed but a lot of comments were not positive. In particular partners raised concerns communication needed to be improved, both within the staff team and with themselves. Some partners gave examples such as appointments being missed, although they did say they felt this had begun to improve recently. More than one partner felt that a health concern could have been shared with them sooner but that most referrals were made in a timely manner. One partner raised concerns that the information they shared did not always get passed on to other carers. Some concerns about documentation were also raised. Feedback on how well staff knew people during partners visits to the service was mixed. Some partners said staff knew people well others said staff did not always know people’s needs.

Learning had not always been effective or led to effective sustained improvements. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. The provider did not challenge improvements to the environment sufficiently by providing constructive criticism on the impact they might have on people. For example, work had been undertaken to improve the dining experience of people. Dining tables were nicely set prior to people coming to eat and staff said they had wanted to create a ‘fine dining experience’. However, the wider context had not been considered. The dining room contacted a commercial style sink and dishwasher. Staff scraped plates and washed dished next to people eating. The noise from this and the dishwasher was very loud and made conversation difficult. One relative told us, “The tables are laid out lovely. They’re [staff] in such a rush at lunch, if I was served something how they do it, I’d send it back”.

We inspected the service in 2023 and rated it inadequate. At the last inspection the service had improved to requires improvement overall and good in well-led. However, the provider had failed to learn lessons and sustain improvement. We found the service was once again in breach of regulations.

However, the manager was arranging learning sessions for staff to improve staff knowledge in some areas. They were also planning to introduce champions in some areas so staff could lead on sharing learning.