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 Inadequate. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

People and their relatives told us the culture had improved at the service, and they were positive about how the service was moving forward. One relative said, “’m not saying staff weren’t caring before, they’re now more empowered, there’s a knock-on effect.” Another person told us, “[the registered manager is] amazing to be honest, the way she’s bought staff together, the staff say she’s the first to listen to them. I can’t praise her enough, she’s always available when you ring. If she’s busy, she will call back. She’s so caring, you can see how much she loves the residents.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leadership had improved and was now clearly driving forward improvements at the service. The registered manager had the skills and experience needed to oversee standards of care and support staff. They were also clearly passionate about the role and improving the lives of the people they supported. One relative told us, “New management came in and it was like someone had breathed new life into the place.” One staff said, “There’s been massive changes, the environment is completely different. It’s home from home. Staff now work as a team, it’s nice to come to work and know who you’re working with and what’s happening.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager was accessible to staff and had a clear presence in the service. Staff, people and relatives all told us they felt they were listened to and were confident in the management of the service. One staff said, “[The registered manager] is a really nice manager, it’s nice when you can knock on the door, if she’s in a meeting, she will say but she comes out on the floor to chat to us.” Another staff said, “I can confidently say that things are better. If you need to speak up the managers do listen now.”

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.

The provider and registered manager ensure staff felt valued and supported. For example, one staff told us how managers made adjustments to help them with some personal caring responsibilities They said, “The manager, you can call her with anything at any time.” Staff were also supported if they wished to observe personal religious practices such as praying during the workday.

The provider did not always have systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Systems were in place to monitor medicines management, including regular audits. However, these were not always sufficiently comprehensive to identify all areas requiring oversight. For example, the service used a monitoring system to alert management when people experienced constipation. For most people, this was set to trigger after three days without a bowel movement. However, for one person, whose assessed needs required management to be alerted after 48 hours, the system had not been updated to reflect this. As a result, the person went 72 hours without receiving their prescribed PRN medicine for constipation. This issue was identified and addressed during the assessment. The findings demonstrated that medicines related quality assurance processes had not always been effective in identifying and responding to exceptions to standard monitoring arrangements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff worked in partnership with other organisations including health and social care professionals to support people. Referrals were made to services were appropriate. Referrals were made to the local authority when there were safeguarding concerns and there was a system in place to recognise when people needed to be referred to the DoLS office for a deprivation of liberty authorisation.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There was now a clear learning culture at the service. Lessons had been learnt since the last inspection and improvements had been made. The registered manager attended events and shared learning with staff. When things went wrong findings were reviewed and lessons learnt. One staff told us, “We use a learning approach rather than a blame one.”