Pine Trees Care Centre

Pine Trees Care Centre is a residential care home providing personal care to 35 people, some of whom are living with dementia. People are primarily aged over 65 years. At the time of the inspection 34 people lived at the service. The home was all on one floor with a range of communal areas. These included a dining space, a lounge and a conservatory.

People’s experience of using this service and what we found

People, relatives and staff were all positive about the management team. Comments from people included “[Managers name] is approachable, he runs a good ship”. Relatives said “[Managers name] is great, he is approachable as is [deputy’s name] and they listen to us”. Staff said, “I have found [managers name] to be approachable and helpful at all times”.

People told us they were happy living at Pine Trees care centre and their care needs were met by caring and skilled staff. Comments included “It’s much better than other homes I’ve been in”, “The food is lovely, its clean, its spotless, my room is lovely, and nothing is too much trouble” and “The staff are always smiling”.

Relatives were complimentary about the care their family members received. Comments included “We are so happy that [person’s name] is here. I know [person] is safe here. When I leave, I’m not worried about [person]. She is in safe hands here. It is the best home” and “The staff are exemplary; they go above and beyond in all aspects of care for [person’s name].”

Safeguarding processes were in place to help safeguard people from abuse

People's care plans were clear and up to date. Risks associated with people's care had been assessed and guidance was in place for staff to follow.

People were supported by enough staff on duty who had been trained to do their jobs properly.

People received their medicines in a safe way.

There were processes in place to prevent and control infection at the service, through regular COVID-19 testing, additional cleaning and safe visiting precautions.

Staff told us that they had received the training they needed to meet people’s needs safely and effectively. The training matrix tracked staff training and this ensured all staff received the training and updates needed to provide safe consistent care.

Staff were supported in their roles through a plan of supervision. Staff told us they felt supported by senior staff and the manager.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The management team maintained oversight of complaints, accidents and incidents and safeguarding concerns. The management team engaged well with health and social care professionals.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection.

The last rating for this service was Good (published 16 October 2019)

Why we inspected

The inspection was prompted in part due to anonymous concerns we received about the management and leadership of the service.

As a result we undertook a focused inspection to review the key questions of Safe, Effective and Well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed and remains Good based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe, Effective and Well led sections of this full report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Pine Trees Care Centre is a residential care home providing personal care to 35 people, some of whom are living with dementia. People are primarily aged over 65 years. At the time of the inspection 22 people lived at the service. The home was all on one floor with a range of communal areas. These included a dining space, a lounge and a conservatory.

People’s experience of using this service and what we found

The service had suitable safeguarding systems in place, and staff had received training about recognising abuse.

Appropriate risk assessment procedures were in place so any risks to people, staff or visitors were minimised.

Staff were recruited appropriately. Staffing levels were satisfactory, and people received timely support from staff when this was required.

The medicines system was well organised and staff received suitable training. People received their medicines on time.

The building was clean, and there were appropriate procedures to ensure any infection control risks were minimised.

The service had suitable assessment and care planning systems to assist in ensuring people received effective and responsive care.

Staff received induction, training and supervision to assist them to carry out their work.

People received enough to eat and drink and suitable assistance when this was required

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People received support from external health professionals and were encouraged to live healthier lives.

People said they received support from staff which was caring and respectful. Care promoted people’s dignity and independence. People were involved in decisions about their care.

People had the opportunity to participate in activities and to spend time with the wider community.

People felt confident raising any concerns or complaints. Records showed these had been responded to appropriately.

The service was managed effectively. People and staff had confidence in the manager.

The manager was able to demonstrate the service learned from mistakes to minimise them happening again.

The service had suitable systems to monitor service delivery and bring about improvement when necessary.

The team worked well together and had the shared goal of providing a good service to people who lived at the home.

The service worked well with external professionals, and other organisations to provide good quality care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (published 9 May 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Pine Trees Care Centre is a care home that provides personal care for up to 35 people, some of whom are living with dementia. At the time of the inspection 21 people lived at the service. All of the people lived there permanently. The home was established on one floor with a range of communal areas. These included a dining space, a lounge and a conservatory.

People's experience of using the service:

¿ Medicines were not always managed safely. The management of external preparations, such as creams and lotions, was not effective. The service could not demonstrate which were in use at the present time. There were not always detailed directions to show where these preparations were to be applied. Records regarding the administration of preparations were not adequate. When medicines were prescribed for use ‘When required’ there was not always sufficient information for staff to administer these correctly. CQC has previously reported on these matters but improvements had not been made. Other medicines were stored, administered, and recorded appropriately.

¿ Risk assessment processes were generally satisfactory to reduce the risks to people. However, we had concerns about how risks were managed in relation to two pressure relieving mattresses and a bed rail.

¿ Infection control procedures were not always effective. For example, hand washing facilities for staff were not always available.

¿ Safeguarding systems were effective.

¿ Staffing levels were currently adequate. However, we did receive some reports of perceived staff shortages at weekends. Although the majority of people said call bells were answered promptly there were some reports of significant delay at this time. Recruitment practices were satisfactory.

¿ Processes to assess whether people had mental capacity were satisfactory and staff had received suitable training in this area.

¿ Staff had received suitable induction and training. The manager had implemented a supervision and appraisal system.

¿ People were supported to receive meals in a timely manner which met their dietary requirements. People told us they liked the food and had enough to drink. Food looked appetising and we judged people received suitable support.

¿ Visiting professionals were positive about staff for example we were told communication between staff and external professionals was seen as good. We were told staff responded appropriately to people’s healthcare needs and professional guidance provided. Records of medical appointments however were inadequate.

¿ The building was well maintained, and well decorated. The building was suitably adapted to meet the needs of people who were elderly and may have physical disabilities. People could personalise their bedrooms.

¿ People who used the service and their representatives viewed staff as caring and supportive. We witnessed staff treating people with dignity and respect, not rushing people and enabling them to have choices. People now had regular opportunities to have a bath or a shower, and to have their hair washed.

¿ Care plans and day to day records did not always contain relevant and up to date information about people’s needs. There was omission of important information about some people’s care needs and what actions staff needed to take to assist them.

¿ There were suitable activities in place and an activities co-ordinator was employed. People said they enjoyed the activities provided. People had the opportunity to sometimes go out on trips organised by the service. Some external entertainers also visited the service.

¿ The service had a suitable complaints procedure. People and their representatives said they would make a complaint if they felt this necessary. Complaints received, and action taken had been recorded.

¿ The service did not have a registered manager, but the current manager was in the process of submitting an application to register to the commission. The manager was viewed by staff positively. The service had a calm atmosphere and was welcoming and friendly. There were systems of resident and staff meetings so these groups could make suggestions and be involved in the running of the service.

¿ The service had a comprehensive system of audits. However we judged these as not always effective as they had failed to pick up the concerns we have highlighted in this report. For example, in respect of medicine management and care planning.

¿ Health professionals felt there was a positive working relationship between the manager and themselves. The service had good links with the local community. The manager positively encouraged feedback and said this was acted on to improve the day to day care received by people at the service.

¿ The management had displayed the latest rating at the home and on the website. When required notifications had been completed to inform us of events and incidents, this helped us the monitor the action the provider had taken.

More information is in the detailed findings below.

We identified breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around care planning, risk assessment procedures, medicines management, recruitment procedures and governance arrangements. Details of action we have asked the provider to take can be found at the end of this report.

Rating at last inspection: Requires Improvement (report published November 2018). CQC took enforcement action after this inspection. This involved us imposing a condition on the registration of the service. The condition meant that the service could not admit new people to use it, without permission of CQC. We also required the registered provider to submit monthly action plans which outlined the actions taken to bring about improvement. The registered provider has complied with the condition.

Why we inspected: This was a planned inspection based on the rating at the last inspection. At this inspection we found that improvements had been made in respect of general care standards. However, we also identified some areas which required improvement.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

The overall rating for this registered provider is 'Requires Improvement'. The location has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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.

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. We will have contact with the provider following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The service was last inspected in January 2018 and was rated as ‘Requires Improvement’. Before this inspection we received whistleblowing concerns about the management of the medicines system, and concerns raised about support people received with personal and health care. The inspection was currently brought forward.

This comprehensive inspection took place on 25, 26 and 27 June 2018 and was unannounced. At the time of the inspection there were 28 people living at the service.

The service had a registered manager. A registered manager is registered with the Care Quality Commission to manage the service. Like providers, they have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was on long term sick leave, at the time of the inspection, but the registered provider had arranged for a general manager to manage the service. The general manager was supported by an acting regional manager. Both managers had been recently employed to oversee this service.

We had significant concerns about the management of the medicines system. For example there had been a failure of the service to obtain satisfactory supplies of medicines for at least eleven people who subsequently did not have prescribed medicines for several days. The management of the service said the failure was due to inadequate communication between GP’s and the pharmacy. However we were concerned there did not appear appropriate action taken by the management of the service to resolve the problems, and ensure people had their medicines. Medicines which were not given included medicines which prevented blood clotting, blood pressure, pain relief, asthma, anti-depressants, medicines to treat thyroid conditions and diabetes. We were also concerned about the recording of the administration of creams which did not satisfactorily give us assurance that prescribed creams and ointments were administered when they were needed.

We were concerned there was not satisfactory evidence that people always received timely support to see a GP or other health professionals when they needed to. This included when people had stomach problems; the lack of appropriate support for one person with attendance to a hospital appointment; the lack of timely and regular liaison with medical professionals when people had lost a significant amount of weight, and the lack of suitable medical records, for example when people saw an optician, chiropodist or dentist, to demonstrate people received suitable medical check-ups when these were required.

People did not receive satisfactory opportunities to have a bath, shower and have their hair washed. There was no record some people had a bath or a shower, or had their hair washed, over a period of several weeks. Some of these people had been regularly incontinent, and although they had been washed there was no evidence they had been offered a bath or shower. The majority of people we spoke with said they only were provided with a wash rather than the opportunity to have a bath or a shower.

Although there were a range of quality assurance procedures in place these were not effective based upon the findings of the inspection. The registered persons were able to demonstrate there was a range of systems in place to check the service. However we would question the effectiveness of these systems as they had failed to detect the problems found at this inspection, and ensure suitable action was then taken to bring about improvements to the operation of the service.

As part of this comprehensive inspection we also checked to see if the provider had made the improvements required following the inspection of January 2018. In January 2018 we found that care was not always person centred, for example we had concerns about the support people received getting up and going to bed; there was unsatisfactory responsiveness of staff to call bells; support people received at meal times was not satisfactory; and records to show staff recruitment procedures were not satisfactory; records to show staff received induction, training and supervision were not satisfactory. The service was at that time rated ‘Requires Improvement.’ Subsequent to the publication of the report the provider submitted an action plan about what steps they would take to improve the service.

At this inspection we found there had been some improvement in these areas. For example recruitment checks were satisfactory. The meal times in the dining room we observed were pleasant and supportive occasions, although we still had concerns about meal time arrangements for some people who spent their time in their bedrooms and were more dependent. Not everyone was happy about the arrangements for assisting them to get up and go to bed. Some people reported significant delays and staff not being able to assist them at a time of their choosing. There were some concerns raised by people, their representatives and staff about staffing levels and staff responsiveness for example to call bells. Many people said call bells were answered promptly, but we did receive on-going concerns from others about responsiveness. For example some people said they had to wait unreasonable amounts of time for help if they pressed the call bell. We have recommended staffing levels, call bell responsiveness and staff sickness be monitored and reviewed.

In respect of induction, training and supervision; we did see evidence that a check list was completed with new staff when they initially started at the service. However there was limited evidence that new staff were completing the care certificate, and there was limited evidence provided about staff completing shadow shifts. There were also gaps in new staff receiving practical training for example in first aid, although completion of eLearning was generally satisfactory. Records to confirm staff members received one to one supervision with a manager were variable, although day to day supervisory arrangements were satisfactory. For example there was always a senior member of staff on duty. We have however given recommendations to improve delivery of induction, training and formal supervision.

We received some positive reports about care staff and care practice. For example people told us: “Staff on the whole are very kind and pleasant,” “Staff are very nice,” “Some are extremely kind. Some are extraordinarily nice,” “They are not rushed, they are all fine.” However some people raised concerns about the attitudes of a minority of staff. People were involved in making decisions about their day to day lives, and to some extent about care planning. We observed staff working in a manner which was caring and kind.

The service provided ground floor accommodation, some bedrooms had en-suite toilets and wash hand basins. There was a large lounge, and a sun lounge leading to a patio area with tables and chairs. The building was well maintained and decorated, with good quality furnishings.

There were suitable safeguarding processes in place. For example the staff we spoke with knew what action to take if they suspected abuse was occurring. The majority of staff had also received satisfactory training. The registered provider could demonstrate, where they had concerns, safeguarding referrals had been made to the local authority. When the service had been subject to safeguarding enquiries, the registered persons had fully co-operative. The service had suitable whistle blowing procedures. However, following this inspection, CQC judged we had concerns about the care of some people who used the service. As a consequence we submitted a safeguarding referral to the local authority to highlight these concerns.

Record keeping was generally satisfactory. Each person had a care plan, and regular records were kept about their care. However some care records were not comprehensive and lacked relevant detail. The service had suitable risk assessment processes in place and people had suitable risk assessments on their files, which were regularly reviewed.

Suitable health and safety systems were in place. The service also had suitable equipment (for example to assist moving and handling). Suitable checks were completed and documented. However the registered provider was not able to locate all relevant records for us to inspect.

The service was generally clean, and suitable infection control procedures were in place. However there was a smell of urine in places. Most people said the laundry system was effective and reliable, although some people said some clothing had gone missing.

The service had taken suitable steps to ensure people’s legal rights were protected in line with the Mental Capacity Act 2005. Staff received training about this. Visiting hours at the service were flexible, and visitors said they always felt welcome.

The service had a comprehensive activities programme. People enjoyed the activities available. The activities included entertainers visiting. Some external trips were organised although we were told the service’s minibus was currently not working. An activities co-ordinator was employed.

We had mixed responses about the operation of the complaints system. Some people and their relatives told us they would feel confident making a complaint and it being responded to appropriately. Other people said, for example, although they were given assurances improvements would occur, these were not acted upon or improvement sustained. The complaints record was incomplete and did not comprehensively list all the complaints wh

At this inspection we found there had been some improvements. However talking to people, their relatives, staff and external professionals, outcomes for people were still mixed. As a consequence we have issued four statutory requirements about person centred care, staff recruitment; induction, training and staff supervision, and support for people at meal times. Overall the service has been rated as ‘Requires Improvement’ as a reflection that although there have been improvements at the service there is still further work the registered provider needs to do to ensure the service is managed to a satisfactory standard where regulatory requirements are met.

Pine Trees is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Pine trees accommodates 35 people.

The service provides ground floor accommodation. Some bedrooms have en suite toilets and wash hand basins. There is a large lounge, and a sun lounge leading to a patio area with tables and chairs. The building was well maintained and decorated, with good quality furnishings.

The service had a registered manager. A manager is a person who has with the Care Quality Commission to manage the service. Like providers, they are ‘persons’. 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. The registered manager was on long term sick leave, at the time of the inspection, but the registered provider had arranged for a general manager, to manage the service.

We had concerns about recruitment records and checks which had taken place regarding staff who had been appointed since the last inspection. For example, some staff employed did not have satisfactory references from previous employers.

We were concerned whether staff induction processes were effective in terms of providing staff new to the care sector with effective training to learn their roles. Records of induction were not always fully completed and there was insufficient evidence to show staff who were new to the care industry had started the Care Certificate, which is an industry wide standard for new care staff.

Support people received at the meal times we observed was not always satisfactory or consistent with good practice. People’s experiences of receiving a satisfactory level of support were variable and not always appropriate. People said they liked the food they received and were provided with a choice.

We received some positive reports about care staff and care practice. For example people said, “The staff are a good lot,” and “I am happy enough here.” Relatives said “(My relative) is happy here. (They) like the staff. I am happy.” “The staff are very good. You can always approach them and they will help you.” However, we continued to receive mixed reports about whether the care people received was appropriate and timely. Some people said they experienced delays in receiving help to get up, delays in staff responding to call bells, and staff did not provide them with appropriate support to go to bed at a time they wanted. Similarly personal care was not always provided at a suitable time.

Safeguarding processes were to a satisfactory standard. For example, the staff we spoke with knew what action to take if they suspected abuse was occurring. The majority of staff had also received satisfactory training. The registered provider had taken appropriate action when they felt people had been at risk of abuse. The service had been subject to a service wide safeguarding enquiry. The registered persons had fully co-operated with this. The local authority has judged satisfactory progress has been made and the safeguarding enquiry has been closed. The service had suitable whistle blowing procedures.

The service had suitable risk assessment processes in place. People had suitable risk assessments on their files. These were regularly reviewed.

Record keeping had improved. Each person had a care plan, and regular records were kept about their care. However we found some gaps in care records which the registered persons needed to address.

Suitable health and safety systems were in place. The service also had suitable equipment (for example to assist moving and handling). Suitable checks were completed and documented.

There were some concerns raised by people who use the service, their representatives and staff about staffing levels and staff responsiveness. We have recommended staffing levels need to be reviewed.

There were improvements about the operation of the medicines system. People received their medicines on time, suitable records were kept, and medicines were appropriately stored. There were still some concerns about the recording of the administration of creams, and the registered persons’ needed to make further improvement in this area. Staff administering medicines had received suitable training.

The service was clean, and suitable infection control procedures were in place. People said the laundry system was effective and reliable.

People received appropriate support from medical professionals. Links with other agencies and professionals such as the district nurse team had improved.

The building was designed, decorated, furnished and maintained to a good standard. People said they were always warm enough.

The service had taken suitable steps to ensure people’s legal rights were protected in line with the Mental Capacity Act 2005. Staff received training about this, but it was not clear whether this was effective in enabling staff to understand people’s rights and staff responsibilities.

People were involved in making decisions about their day to day lives, and to some extent about care planning. Most of the time, we observed most staff working in a manner which was caring and kind.

Visiting hours at the service were flexible, and visitors said they always felt welcome.

All people had a care plan and these were regularly reviewed. Some staff still had not had time to read care plans and required training to use the electronic system. Care record keeping had improved since the last inspection although we highlighted gaps in recording of important information to enable staff to effectively deliver good care.

The service had a comprehensive activities programme. People enjoyed the activities available. The activities included entertainers visiting. External trips were organised. An activities co-ordinator was employed.

Improvements had been made to the operation of the complaints system. Complaints received had been recorded, and there was an outline of action taken. People and their relatives had more confidence in the operation of the system.

The service had a suitable approach to end of life care. Suitable records were kept. Some staff had received training about end of life care.

The registered provider had ensured the service received extensive support from national and regional management since the last inspection to bring about improvement to the service. This has resulted in noticeable improvements to some aspects of the service since the last inspection. However, this report has resulted in the service not meeting regulatory standards regarding staff recruitment, and staff induction, training and supervision. We also had significant concerns about the support people received, from staff, at mealtimes. We have also repeated ongoing concerns about the adequacy of staffing levels, care planning, staff responsiveness, recording of the administration of some medicines, and communication, at times between staff, and also between staff and external professionals. These matters were not detected, and/ or appropriate action taken, by the registered provider since the last inspection.

The registered manager has been on long term sick leave, but suitable interim management arrangements have been in place since that time. Staff recognised the general manager had a difficult job to make improvements at the service, but the staff and people’s relatives, respected her and supported the changes she was making.

The manager and registered provider demonstrated a clear ethos, and have introduced new systems and procedures which have resulted in improvements, in some significant areas, to outcomes for the people who used the service.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 inspected Pine Trees Care Centre on 17,18,19 July 2017. The inspection was unannounced. We last completed a comprehensive inspection in February 2017 when it was rated as ‘requires improvement’. We found the service was not meeting the regulations in respect of how medicines were managed, or having satisfactory staffing levels. For both of these matters we issued warning notices. The registered persons were also not ensuring: the Care Quality Commission was notified of incidents required by law; there was an effective complaints procedure; there was a satisfactory quality assurance procedure, and recruitment checks completed on new staff were satisfactory.

In May 2017, we completed a focussed inspection to check if there had been improvements about medicines management. Although we concluded there had been some improvement, there were some outstanding issues which need to be resolved such ensuring all care plans had written protocols for ‘when required’ medicines, improving records about the administration of creams, improving the recording of refrigerator temperatures and improvement regarding staff training.

At the last comprehensive inspection we judged staffing arrangements were not satisfactory. For example staff were observed as being very busy, and there were delays in answering call bells. At this inspection we noted improvement in how staffing was organised. A deputy manager had also been appointed. There was a much calmer atmosphere at the service. However we still received some concerns, from staff and people who used the service, about staffing levels, and about the responsiveness of staff to call bells. We have recommended that staffing levels are kept under review.

We judged that people using the service were not safe. We received some positive comments from people, their relatives and staff. However, we had significant concerns about the care and treatment of some people, and how the registered persons had responded to one issue where an allegation of physical abuse had been made. Multi-disciplinary safeguarding investigations had concluded concerns about the practice of some staff; inappropriate and neglectful care practice received by some people, and concerns about the support received by some people with pressure care, mobility, and eating and drinking. Further investigations are ongoing, and the local authority had suspended further placements at the service. We were made aware of an incident, which occurred several months ago was not reported to CQC. Documentation about the fact finding investigation carried out by the registered manager was unsatisfactory, and when we requested a full report of the investigation, we received no response. The matter is currently considered by the local authority as a safeguarding issue, but at the time of writing the local authority officer also confirmed they had not received the requested report.

We were concerned about how risks were managed at the service. For example risk assessments were not being routinely reviewed, and we were concerned that suitable action was not being taken where there was evidence that people were at risk or subject to pressure sores, lack of hydration and good nutrition.

There was evidence that moving and handling equipment was not being used appropriately and this, for example, created a risk to people’s safety.

We were concerned about the service being well led. At the last comprehensive inspection we judged quality assurance and audit systems as not satisfactory. This inspection has resulted in a significant number of breaches in the regulations. Some of the breaches in the regulations which we highlighted at the inspection in February 2017 have not been complied with. Although we have not said there is an ongoing breach in the regulation about staffing levels, we have issued a recommendation that staffing levels are kept under review as there were still some concerns expressed about their adequacy. The registered persons have not taken suitable action to ensure suitable systems are in place to ensure standards, for example regarding care documentation, and care for the more vulnerable people at the service are looked after appropriately.

We had significant concerns about the maintenance and availability of satisfactory records within the service for example in respect of care records; staff supervision and induction and to demonstrate good governance.

We subsequently had significant concerns about the current management of the service and the ability of the registered persons to bring about improvement.

The environment was generally clean and well maintained. However we were concerned about how some potential infection control risks such as there not being enough anti-bacterial gel available.

Staff recruitment checks were adequate although the registered persons did not always obtain suitable staff references.

We had concerns about people not having suitable documentation when deprivation of liberty safeguard orders were needed to be put in place. These are required, under the Mental Capacity Act 2005, to protect people from risk, due to their lack of capacity to make decisions for themselves. The people we spoke with did not feel they had unnecessary restrictions in place for example people said they could move around the building as they wished, and get up and go to bed when they liked.

People were happy with food provided. For example we were told meals were “Lovely,” and “Excellent.” We observed people received suitable support at meal times. However records and procedures in place to assist people at risk of dehydration and malnutrition, and to support people with diabetes, were not satisfactory.

Overall, the provision and delivery of staff training was satisfactory, although some staff had not completed all training required by law. There were not satisfactory records of induction for some staff who had commenced employment since the last inspection. Staff said they had someone to one supervision meetings with a senior member of staff, but there were insufficient records in place to verify this occurred. Staff however told us they felt supported by senior staff and their colleagues.

Care records were not satisfactory, did not suitably detail people’s current needs, and were not regularly reviewed. The registered persons were in the process of setting up an electronic care planning system, but paper records were not being effectively maintained until this was implemented.

At the previous inspection we had concerns about the effectiveness of the service’s complaints procedure. At this inspection most people we spoke with, and their relatives, said they had confidence that complaints would be addressed. However one person who made a complaint told us although their complaint had been acknowledged, it had not been investigated. We found no record of this in the service’s complaints record.

People could see a GP or other medical professional such as a dentist as necessary. However records were not sufficient for us to check when people last saw some medical professionals.

The building was suitably adapted, for example for people with physical disabilities, well decorated and had clean and comfortable fixtures and fittings. There were no unpleasant odours.

People viewed staff positively. People said their privacy was maintained, and they were treated with respect and dignity. Comments received included: “They are lovely,” “Very kind,” and “Nice.” We also observed staff working in a kind, professional and caring manner. People looked well cared for, although some relatives and external professionals said some people’s personal care was not consistently maintained.

People had the opportunity to participate in a range of activities. These included quizzes, bingo, and arts and crafts. Some trips out were arranged. Events such as religious festivals and cultural celebrations such as St Piran’s Day were celebrated.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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 t

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 previously carried out a comprehensive inspection of Pine Trees Care Centre between 1 February 2017 and 6 February 2017. At that inspection we identified six breaches of the legal requirements. The breaches related to how medicines were managed; staffing levels; staff recruitment checks; CQC not being notified about matters the provider was legally required to tell us about; the complaints procedure, and quality assurance processes. Two warning notices were issued regarding medicines management and staffing levels. Statutory requirements were issued about the other four breaches in the regulations. The provider sent the Care Quality Commission an action plan about the four requirements, and about actions taken regarding medicines management. We have also requested a report about actions taken regarding our concerns about staffing levels but this has not as yet been received.

We carried out this focused inspection to check if the registered persons had taken suitable action about the warning notice issued about the management of medicines. The other breaches in regulations will be looked at again at future inspections.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pine Trees Care Centre on our website at www.cqc.org.uk

During this inspection we checked the service’s medicines system. The organisation of the medicines system had improved but we still found some errors. For example there were some medicines which had been signed for but had not been administered. There were some medicines which had been administered but not signed for. Eye and ear drops and ointments were not labelled when they were opened for use. These should be disposed of after four weeks of use. Some of these medicines were being used, but had been dispensed more than four weeks before the inspection. Records about the administration of creams had improved, but still lacked sufficient detail to demonstrate they were being administered according to prescription instructions.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 inspected Pine Trees Care Centre on 1, 2 and 6 February 2017. The inspection was unannounced. The service was last inspected in April 2016 when it was found to be not meeting the regulations in respect of how medicines were managed.

People told us they felt safe at the service and with the staff who supported them. We had concerns that a statutory requirement issued in April 2016 about the operation of the medicines system had not been complied with. We found a significant number of errors with the operation of the medicines system for example medicines being given but not signed for, and medicines being signed for but not given. We were also concerned about whether prescribed creams were being applied as necessary, and whether records of prescribed creams were being suitably kept.

We were concerned whether staffing levels was satisfactory to meet people’s needs. Staff were observed as being very busy. This was particularly the case in the mornings when call bells were constantly sounding. We received concerns that people could have to wait up to 20 minutes for call bells to be answered, and this caused some people anxiety. There were some concerns whether people received their meals, or support with eating, due to the staffing available at the service. Some staff members told us meeting people’s needs could be difficult, particularly in the mornings, and particularly if there was staff sickness.

Staff recruitment checks were not always completed as required. For example some new staff lacked two written references. One person did not have a Disclosure and Barring Service check, on their file, which is seen as necessary as evidence the person is fit to work with vulnerable adults.

People viewed staff themselves positively. Comments received included staff were “Excellent”, and “Very kind.” Relatives were also positive about the attitudes of most staff.

The environment was clean and well maintained. Health and safety checks were all completed appropriately, although the upgrading of the service’s electrical circuit has been deemed as ‘unsatisfactory’. We have been told this matter will be addressed shortly.

The service had suitable policies and procedures in place to ensure new staff received comprehensive induction, training, supervision and appraisal. However records showed there were gaps in the delivery of this training and support, for example, staff did not receive training to obtain the Care Certificate (A nationally recognised industry standard) within 12 weeks of employment.

People were happy with their meals. For example, comments we received included food was, “Very Good,” “Lovely,” and “Excellent.” The meal time we observed was a pleasant occasion. We did receive some concerns about people not receiving meals, and people not receiving timely and appropriate support with eating.

People said they had access to relevant health professionals. Records showed, the sample of people we assessed, had seen a GP, district nurse, optician and a dentist.

People and their relatives mostly viewed staff as caring. For example, comments we received included, “All nice…I could not want anything better” and “The home is very good.” Staff were observed working in a kind, professional and caring manner. People said their privacy and dignity was respected, and they could see visitors when they liked.

We were concerned about how some complaints had been handled. Two complainants told us they were not satisfied how the matters they had raised had been dealt with. CQC has referred these matters, for investigation, to the registered provider. We were concerned that all complaints were not recorded in the service’s complaints record. We were also concerned the frequency of complaints had risen since the beginning of 2017, and we have requested a copies of investigations of these complaints due to the concerning nature of the issues raised.

People all had a care plan, these were comprehensive and regularly reviewed.

The service had a comprehensive range of activities. An activities co-ordinator was employed five days a week. Activities on offer included bingo, quizzes, gardening and baking. There were some external entertainers who visited the service. Some trips were organised using the service’s minibus.

We were concerned about how the quality of the service was monitored. Although there were comprehensive systems of quality assurance in place, we were concerned about their effectiveness in picking up some of the issues which were readily apparent, and raised by people, with us.

We were concerned that at least one matter which should have been reported to CQC by law was not reported to us. It is important matters such as safeguarding issues are reported to CQC so we can check, as necessary, that suitable action has taken place to ensure people are safe.

Management of the service was generally viewed positively, although some people thought the manager should be more visible. There was a positive culture in the team, and suitable ways for the team to communicate with each other. However some concerns were raised about staff sickness, and that information discussed at shift handovers could be more comprehensive.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 inspected Pinetrees on 28 and 29 April 2016. The inspection was unannounced. The service was last inspected in September 2014 when it was found to be meeting the requirements of the regulations.

People told us they felt safe at the service and with the staff who supported them. People told us, “I am very safe,” and “Yes staff are nice to me. There are no concerns. ” A relative said “Staff are very caring. People are very well looked after and very safe,” A health professional told us “Pine Trees has improved a lot. I think the service is safe now.”

People told us they received their medicines on time. We had some concerns about the completion of medicines administration records, and have required the service to make improvements in this area. Medicines were stored appropriately and staff who administered medicines received suitable training.

Staff had been suitably trained to recognise potential signs of abuse. Staff told us they would be confident to report concerns to management, and thought management would deal with any issues appropriately.

Staff training was delivered to a good standard, and staff received updates about important skills such as moving and handling at regular intervals. Staff also received training about the needs of people with dementia.

Recruitment processes were satisfactory as pre-employment checks had been completed to help ensure people’s safety. This included written references and an enhanced Disclosure and Barring Service check, which helped find out if a person was suitable to work with vulnerable adults.

People had access to medical professionals such as a general practitioner, dentist, chiropodist and an optician. People said they received enough support from these professionals. However records of when people had last seen a dentist were variable.

During the inspection, there were enough staff on duty. Most people said they received timely support from staff when it was needed, although we did receive some concerns that staff responses could be slow, or staffing levels were variable for example at the weekends. Throughout the inspection we however saw that call bells were answered promptly and we saw staff attending promptly to people’s needs.

The service had a programme of organised activities, and an activity organiser was employed. Activities included quizzes, bingo, cookery sessions and regular events such as garden parties. Some external entertainers such as musicians and singers visited.

Care files contained information such as a care plan and these were regularly reviewed. The service had appropriate systems in place to assess people’s capacity in line with legislation and guidance, for example using the Mental Capacity Act (2005).

People said they were very happy with their meals and people were provided with a choice. Everyone said they always had enough to eat and drink. Comments received about the meals included “The food is very good,” and “The meals are cooked nicely.” We observed a lunchtime, which was a sociable occasion where people received suitable support.

People we spoke with said if they had any concerns or complaints they would feel confident discussing these with staff members or management, or they would ask their relative to resolve the problem. They were sure the correct action would be taken if they made a complaint.

People felt the service was well managed. People told us the manager is “Very Nice.” Staff told us the manager was “Approachable,” and “Very nice.” There were satisfactory systems in place to monitor the quality of the service.

This was a responsive inspection which we completed due to concerns received about the standards of care and staff practices at the home. It was alleged staff, at times, did not conduct themselves in a professional manner. It was alleged some care practices needed improvement for example moving and handling, and ensuring people could go to the toilet when they wanted. It was alleged there was inadequate staffing. We were also told people were not provided with a choice of food, and the standard of the catering was not satisfactory.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report. We would also refer the reader to our report dated 9 and 10 June which was a full scheduled inspection.

Is the service safe?

Yes, overall on the day of the inspection, and based on the findings of our inspection in June we judged the service was safe.

People told us they felt safe and secure. The people we spoke with were positive about the staff who worked with them. People told us staff were caring and supportive. For example people told us 'Everything is fine, I am happy here,' and 'I am very happy here. I cannot think of anything I could moan about.'

People said their personal care was well attended to, and if they rang the call bell staff would come to assist. Some people did say that at times they would have to wait for assistance but overall the waiting times were deemed as acceptable. For example we were told: 'Sometimes it is better than others'.it depends if they are busy, but I have never been left,' and 'The call bell is answered fairly promptly, but I have never been left.' 'They always answer the bell promptly.'

Some people told us occasionally only one member would assist them with moving and handling, when specialist equipment was being used and two members of staff should assist them. Failure of staff to follow moving and handling procedures correctly could put people at risk. However other people said they had not experienced this happening and there were always two members of staff who assisted them. We raised this matter with the registered manager, and subsequently she discussed this matter, at a staff meeting, on the day of the inspection. The registered manager said she would monitor the matter closely.

According to staff rotas satisfactory numbers of staff were provided to meet people's needs throughout the day and night. Records showed there was some sickness absence, but this did not appear excessive. The registered manager said the organisation had appropriate procedures to monitor staff sickness. We were told human resources procedures were used if individual staff took excessive periods of sickness absence.

Is the service effective?

Yes, on the day of the inspection, and based on the findings of our inspection in June we judged the service was effective.

People all had an individual care plan, which set out their care needs. Care plans contained satisfactory information and were accessible to staff.

People said staff met their needs and responded appropriately when they needed assistance.

People were generally positive about the meals provided and said they were provided with a choice of meals. For example we were told: 'the food is very good, there is a choice'I have no complaints,' and 'it is very good, and there is a good selection. People said they were provided with regular drinks throughout the day.

Is the service caring?

Yes, on the day of the inspection, and based on the findings of our inspection in June we judged the service was caring.

Our observations of the care provided, discussions with people and records we assessed, enabled us to conclude individual wishes and needs were taken into account and respected.

People who used the service said they were supported by caring and professional staff. Comments from people who lived at the home included 'staff work hard, I always feel included in the conversation when staff are helping me,' 'staff are always polite,' and 'yes the staff get on, they have a chat and a laugh....there is a good atmosphere here.'

Is the service responsive?

Yes, on the day of the inspection, and based on the findings of our inspection in June we judged the service was responsive.

The people we spoke with all said the staff treated them with respect and dignity. Care practice was judged as professional and supportive. For example we were told 'I had an infection and the staff spent all night with me'they could not do any more.'

People told us when they needed help staff would assist them appropriately and usually in a timely manner. For example we were told: 'I sometimes have to wait, but it is generally not too bad,' and 'they will answer the bell promptly'they don't dally.'

Is the service well-led?

Yes we judged the service was well led.

People who used the service and a relative we spoke with were positive about the management of the home. People told us the staff and management were approachable, and would resolve any problems if they voiced any concerns. For example we were told 'the manager is very nice,' and 'I have no complaints, the staff are goodness itself.'

We raised a concern with the manager that some of the people who used the service said they had occasionally only received assistance from one rather than two members of staff with moving and handling. The registered manager who discussed the matter with the staff at a meeting that day, said she would address the matter with other staff that were not present, and said in future the matter would be monitored closely.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Yes, we judged the service was safe.

People told us they felt safe and secure. The people we spoke with were on the whole positive about the staff who worked with them. People told us staff were caring and supportive. For example, one person said 'staff are very caring'they are as good as gold.'

The staff that we spoke with said they had confidence in colleagues' practices. Staff told us if they had any concerns about how people who used the service were cared for the registered persons would take their concerns seriously. For example, we were told 'there is no poor care here, if so management would take appropriate action to deal with it.'

The home had suitable safeguarding procedures. Staff had received appropriate training to recognise signs of abuse. The people who lived in the home said they had confidence approaching senior staff in the home if they had any concerns about staff practice.

The home had an effective medication system. Medication was stored and administered appropriately. Suitable records were maintained regarding the receipt, administration and disposal of medication.

We saw that the home was well designed and maintained. Decorations and furnishings were well maintained and comfortable. Equipment was well maintained and regularly serviced.

On the days of the inspection the home was clean and there were no unpleasant odours. The people who used the service all said they were happy with the standard of cleanliness. People said the laundry service was satisfactory.

We inspected the staff rotas, which showed that there were sufficient staff on duty to meet people's needs throughout the day and night. People said call bells were promptly answered and on the whole staff were unrushed and patient with them.

Is the service effective?

Yes we judged the service was effective.

People all had an individual care plan, which set out their care needs. Care plans contained satisfactory information and were accessible to staff.

People said staff met their needs and responded promptly when they needed assistance.

People had access to doctors, district nurses, chiropodists and opticians, although some improvement was required regarding documenting the support received from some external medical professionals. We spoke with two external medical professionals. They said they had confidence in the staff and they felt people in the home were well cared for.

People were generally positive about the meals provided. From our observations we found people received appropriate support at meal times.

Staff had sufficient training to carry out their roles. The people who used the service, who we were able to speak with, said they thought the staff were professional and knew what they were doing. The staff members we spoke with said they thought they received appropriate training. However we judged some improvement was required to record keeping regarding the training staff had received.

Is the service caring?

Yes we judged the service was caring.

Our observations of the care provided, discussions with people and records we assessed, enabled us to conclude individual wishes and needs were taken into account and respected. There was a programme of activities available for people. The home had an activities co-ordinator who worked at the home each weekday.

People who used the service said they were supported by caring and professional staff. We were positive about the care practices we observed. Comments from people who lived at the home included 'It is very nice' very good. The staff are very kind. If I ring the call bell they come at once' and 'The staff are very good. They are friendly and polite.' A relative told us 'it is magnificent'I cannot fault them.'

Is the service responsive?

Yes we judged the service was responsive.

The people we spoke with all said the staff treated them with respect and dignity. The care practice we observed was professional and supportive. For example a person who lived in the home told us 'it is very good. The staff are very good. They do their best to help us.'

The home had a satisfactory complaints procedure. Information about how to make a complaint was provided to people who used the service. The people who used the service, who we spoke with, said they would feel confident speaking with staff if they had any concerns or complaints, and they felt these would be resolved appropriately.

Is the service well-led?

Yes we judged the service was well led.

Staff, people who used the service and their relatives were all positive about the management of the home. People told us the staff and management were approachable, and would resolve any problems if they voiced any concerns.

The home had a satisfactory quality assurance system to monitor the quality of the service and ensure suitable improvements took place where this was necessary.

There were enough qualified, skilled and experienced staff to meet people's needs.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

People told us the staff were 'fantastic' and the food was 'lovely'.

We saw that everyone who lived at Pine Trees Care Centre had a care plan in place which informed and directed staff on how to care for a person.

Pine Trees Care Centre operated an effective recruitment procedure in order to ensure people the registered persons employed were of good character, suitably qualified, skilled and experienced.

On occasion the home had been understaffed. People who lived at the home and one relative explained that call bells were not answered promptly. Staff in the home explained they worked hard but due to high levels of staff sickness at times it was difficult.

The policy for covering staff sickness had not been followed.

We reviewed the records held in the home. Documentation, such as food and fluid charts were not consistently completed to reflect how much a person had consumed.

The home did not have an effective system in place to ensure the disposal of confidential waste.

We saw privacy and dignity were mostly respected during our visit, although we observed staff entering bedrooms that had doors open without requesting permission to enter. Staff talked to people and offered them assistance. We saw that peoples wishes were respected. We observed people moving around the home without restriction.

We did not see evidence that showed people who used the service and/or their representatives were involved with the development or review of their care plan.

During our inspection we spoke to people who used the service and staff. People told us that they had a choice of food and that is was 'lovely and hot'. We observed people being able to choose what they wanted to eat and saw that alternatives to the planned menu were available.

We found that staff had not been sufficiently trained and that the number of staff on duty did not reflect the needs of the people that used the service.