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Archived: PineHeath Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 19 July 2017

This inspection took place on 28 March 2017 and was unannounced. Our previous inspection carried out on 10 and 15 November 2016 identified eight breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This inspection found that limited improvements had been made and determined that the provider was still in breach of seven of the same regulations. Three of these regulations were in breach for the third consecutive time as a result of an inspection.

Pineheath is registered to provide accommodation and personal care for up to 44 people. At the time of this March 2017 inspection there were 28 people living at the service, some of whom were living with dementia.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found considerable maintenance issues that had not been addressed, including window and drainage problems. Safety concerns relating to unlagged hot pipes and unprotected heated towel rails that had been identified during our November 2016 inspection had not been addressed. We again found cleanliness and infection control issues that could put people at risk.

Plans to identify and mitigate risk to people in relation to their health were not clear. We had concerns about people not receiving prescriptions promptly which meant that they did not receive treatment for health conditions to help reduce their symptoms.

Despite training being received about the Mental Capacity Act 2008 there was minimal understanding and poor adherence to the requirements to ensure that people’s rights were protected. There were substantial gaps in staff training so people could not be sure they were being supported in a safe and appropriate manner.

We again observed considerable poor practice that was not respectful to people and did not uphold their dignity.

People’s care records were not clear, accurate or up to date. They did not provide staff with sufficient guidance about how people’s needs should be met.

The provider remained minimally engaged in the day to day running of the home. Despite the significant improvements required they had failed to improve their oversight of the service or provide enough support in order that improvements could be made.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually

Inspection areas

Safe

Inadequate

Updated 19 July 2017

The service was not safe.

The service was poorly maintained. People were at risk because of risks from the premises and poor infection control.

Risk assessments were not always clear about how risks to people were to be mitigated.

Medicines were not always available for people when they needed them.

Effective

Inadequate

Updated 19 July 2017

The service was not effective.

There remained little understanding and poor application of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.

Whilst staff training had improved, there were still large numbers of staff who had not received all their necessary training.

People had regular access to a range of healthcare professionals.

Caring

Requires improvement

Updated 19 July 2017

The service was not consistently caring.

Whilst some staff were caring and respectful of people other staff did not always treat them with respect and promote their dignity.

Responsive

Requires improvement

Updated 19 July 2017

The service was not consistently responsive.

People had care plans in place. However, these did not always provide guidance for staff which meant some people may not receive care in line with their needs.

People and their relatives were confident that the manager would act upon any concerns they raised.

Well-led

Inadequate

Updated 19 July 2017

The service was not well led.

The provider did not have sufficient governance and oversight of the service.

They had failed to take adequate corrective actions to improve the service since our previous inspection in November 2016.