The Pines

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 – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had effective systems in place to monitor and review incidents and accidents. The registered manager and area manager showed us an incidents and accidents log and explained how this information was analysed to identify any emerging trends. Where trends were identified, such as behaviours that challenged, they worked closely with staff and relevant health and social care professionals to support people to better manage their behaviours.

The Registered Manager described the processes in place to share lessons learned and provided examples of how learning had been embedded into day to day practice to help reduce the risk of similar incidents occurring in the future. For example, where there had been an identified risk of a person using a kettle in an unsafe manner additional measures were put in place. The person’s care plan was updated and these updates were documented in the communication book and handover folder to ensure all staff were aware. The changes were also discussed during staff supervisions and team meetings to reinforce learning and promote consistent practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Assessments of people’s needs, risks, and wishes were completed prior to admission and were regularly reviewed to ensure they remained reflective of people’s current needs. Relevant information was shared with other healthcare services, including hospitals, when required. For example, people had hospital communication passports in place, which detailed their healthcare and support needs to assist professionals in providing appropriate care.

The service followed a structured transition process to support people moving into the service. This included completing an initial assessment, offering transition visits, and arranging an overnight stay where people were supported to have a meal and experience the service before admission. Staff told us they felt well supported when welcoming new people into the service and had access to the information they needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider had effective procedures in place to protect people from abuse. Staff told us, and training records confirmed, that they had received safeguarding training and understood their responsibilities. Staff said they felt confident that any concerns they raised would be taken seriously and managed appropriately. One staff member told us, “If I became aware of any concerns, I would inform the management team. I would inform the local authority safeguarding team.”

The registered manager understood their responsibility to report safeguarding concerns to the appropriate authorities. Safeguarding incidents had been logged, investigated, and where required, referrals were made to the local authority and notifications submitted to CQC

Where it was necessary to deprive people of their liberty to keep them safe, the provider ensured that Deprivation of Liberty Safeguards (DoLS) applications were submitted to the relevant local authority. All applications had been made in line with DoLS legislation, ensuring people’s rights were protected. The registered manager maintained oversight of DoLS applications, authorisations, and any associated conditions. Training records evidenced showed that all staff had received training in the Mental Capacity Act (MCA) and DoLS.

Throughout the inspection, we observed positive examples of staff supporting people safely. Our review of safeguarding processes confirmed that ongoing and completed safeguarding incidents were managed effectively, with outcomes and actions clearly documented.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider worked with people to understand and manage risks in a holistic way. Staff delivered care that was safe and supportive while enabling people to take positive risks and engage in activities that were important to them.

People had individual risk assessments in place covering areas such as choking, falls, accessing the community safely, eating and drinking, bathing and showering, risks to themselves and others, and mental health relapse. People also had personalised emergency evacuation plans, which detailed the level of support they would require to evacuate the building safely in the event of an emergency.

People received safe care from staff who understood how to identify and manage risks effectively. A staff member described how they supported people who displayed distressing behaviours by recognising early signs and changes in behaviour, avoiding known triggers, and using reassurance and distraction techniques to reduce anxiety and promote safety.

One relative told us, “[Name of relative] is definitely safe. The manager goes beyond. They are really good with them. They relate to [Name of relative] and takes them under her wing which is lovely”.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design and layout of the premises were safe and met people’s individual needs. People had their own bedrooms, which they were encouraged to personalise with their own furniture and belongings to make them feel comfortable and at home.

A person using the service showed us their room and told us, “These are all my things I like in my room.”

The provider ensured that the environment and equipment were safe and well maintained. Regular servicing and safety checks were completed, including for the fire alarm system, portable electrical appliances, and gas safety. Checks were also carried out on window restrictors, and regular fire drills took place. People had individual emergency evacuation plans in place, which clearly outlined the level of support they would require to evacuate the building safely in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager shared staff rotas and explained that staffing levels were planned in line with the needs of people using the service. Where additional staffing was required to support social activities or attend healthcare appointments, this was built into the rota. We observed that there were sufficient numbers of staff on duty to meet people’s needs and to keep them safe. One relative told us, “There are enough staff and they are well trained”.

The provider had safe recruitment procedures in place. Staff files confirmed that appropriate pre‑employment checks had been completed before staff commenced employment. These included verification of employment history, right to work in the UK checks, references from previous employers, and Disclosure and Barring Service (DBS) checks. DBS checks help employers make safer recruitment decisions by providing information about any relevant convictions or cautions held on the Police National Computer.

Staff had the knowledge and skills required to meet people’s needs. The registered manager told us that all staff completed an induction aligned with the Care Certificate, which sets out the expected knowledge, skills, and behaviours for roles within health and social care. Staff had received training relevant to people’s individual needs, including mental health awareness and managing distressing behaviour. Staff had also completed Oliver McGowan mandatory training, which aims to improve the care and support provided to autistic people and people with a learning disability. Staff told us, and records confirmed, that they received regular supervision and appraisals from their managers.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was observed to be clean throughout and free from unpleasant odours. Daily cleaning routines were in place, and staff told us they were provided with appropriate personal protective equipment (PPE) when required. We reviewed records of infection prevention and control audits completed by the provider, which demonstrated ongoing monitoring of cleanliness and hygiene. Training records confirmed that all staff had received training in infection prevention and control. One relative told us,” It's so clean and tidy. They've not long had the kitchen done”. Another relative told us, “They use PPE, I've seen it. It’s clean and tidy, we’ve been a few times now and it’s clean and tidy.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and in line with prescribed guidance. Medicines were administered by trained staff who had completed up‑to‑date medication competency assessments.

Medication administration records (MARs) were completed accurately, with clear staff signatures, and reasons for medicines not being administered were recorded. ‘As required’ (PRN) medication protocols were in place and provided clear guidance for staff on when and how these medicines should be administered. Medicines were stored securely in locked cabinets within the service. Controlled drugs were stored in dedicated controlled drug cupboards and managed in accordance with regulations.

The management team carried out regular audits of medication practices to ensure they remained safe and effective. Where issues were identified, action plans were implemented and monitored to completion.

The registered manager told us the service was following the principles of the Stopping Over Medication of People with a Learning Disability, Autism or Both (STOMP) programme. This National Health Service NHS England initiative aims to reduce the inappropriate prescribing of psychotropic medicines and is a priority within the NHS Long Term Plan.

Where medicine errors had occurred, these had been investigated promptly. Records showed that learning outcomes were documented, and staff involved received competency assessments and refresher training.

People and their relatives told us they had no concerns regarding medicines administration, and feedback indicated confidence in how medicines were managed within the home. One relative told us, “I’m not aware of any medication errors. They facilitate the medical review.” Anther relative told us, “[Name of relative] meds are all sorted. Any problems they phone me of any changes.”