Pine Tree Court Care Home

Pine Tree Court is a residential care home providing personal and nursing care to 18 older people living with dementia at the time of this inspection. The service can support up to 40 people.

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

People’s needs had been assessed. However, people were at risk of not always being protected from harm or inappropriate care as their care plans did not always provide current or clear guidance for staff to follow on how to mitigate their risks. Care plans had not always been updated where people’s needs had changed or when lessons had been learnt from incidents or accidents.

The service was not always following all aspects of the governments COVID-19 guidance. Management took immediate action to ensure they were following current guidance.

Safe recruitment practices had not always been followed and pre-employment checks had not always been undertaken to gather assurances about staff’s previous employment and conduct.

People and their relatives felt the service was safe and that there were enough staff to meet people’s needs.

Staff, people and relatives spoke positively about the management and the support they received. While monitoring systems were in place to manage the services, the service records did not always show how risks were being mitigated while action was being undertaken.

People's medicines were managed and administered well. Management and staff worked with people’s representatives and healthcare professionals to ensure people’s needs were reviewed and care was carried out in their best interest.

Care staff used personal protective equipment (PPE) and supported people to reduce the risk of infection.

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 18 May 2019)

Why we inspected

This inspection was prompted by a review of the information we held about this service. This included information about staffing and fire safety processes in the service.

As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pine Tree Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We made a recommendation to support the provider’s oversight of the quality monitoring systems.

We have identified breaches in relation to safe care and treatment and safe recruitment practices at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

¿ A process of extra infection control measures had been put in place to reduce the risk of spread of infection by visitors to the home including staff, family members, health care professionals and external contractors. For example, hand washing facilities and hand sanitiser was available to visitors and their temperature was checked when they entered the building.

¿ The provider was making progress in providing alternative arrangements for families to visit and see their relatives in a shielded and warm area via a designated booking system.

¿ Staff were supported to minimise the risk of transmitting the spread of infection in the service such as changing into clean uniform at the start of each shift. Staff had had access to and wore (personal protective equipment) PPE appropriately. We observed them regularly sanitising their hands and changing their PPE. Safe processes were in place to safely dispose of contaminated items such as PPE.

¿ Staff had been trained in current infection control practices. The interim manager was reviewing staff health questionnaires which would update staff Covid-19 risk assessments. We have recommended that staff risk assessments include Covid-19 risks relating to staff from BAME communities and be extended to include risks relating to the use of agency staff.

¿ Clinical Covid-19 risk assessments had been put in place for all people. However, we have recommended that the provider extends the risk assessments to include risks relating to people from BAME communities, those people who may refuse to take a Covid-19 test and those people who walk with purpose and are at risk of transmitting or contracting the virus.

¿ Staff regularly monitored the well-being of people such as twice daily temperature checks to identify any soft signs of the virus. A regular testing programme was in place to test both people and staff.

¿ Enhanced cleaning regimes had been implemented to reduce the spread of infection.

¿ Plans were in place to zone the home if people were admitted into the home or people showed signs of the virus, tested positive or if there was an outbreak of Covid-19 in the home. We were told a cohort of staff and a regime of care delivery would be implemented to reduce the spread of infection.

¿ The interim managers of the service championed and monitored the home’s infection control practices. Plans were in place to identify and train a senior staff member to become the home’s infection control lead. They would be responsible for the management and structure of infection prevention and control in the practice and oversee the delivery of infection control related policies and their implementation.

¿ Systems were in place to monitor the quality of the home’s infection prevention control practices which supported and informed the home’s policies and their action and contingency plan.

¿ The provider’s Covid-19 and related infection control policies and contingency plan was regularly updated to reflect current guidance.

Further information is in the detailed findings below.

People’s experience of using this service:

• People and their relatives were positive about the quality of care provided. One relative said, “I can honestly say that the staff are good, they notice things and deal with the more difficult people, stay calm and cool without retaliation”.

• People were cared for by staff who were kind and caring. We observed staff frequently engaging with people in a respectful and friendly manner. The atmosphere of the home was bright and welcoming. Improvements had been made to the home’s decoration and environment to help people orientate themselves around the home.

• People were cared for by staff who knew how to keep them safe and protect them from avoidable harm. Plans were in place for staff to receive additional training to support them to effectively care for people.

• Sufficient staff were available to meet people's needs during the day. The acting manager was reviewing the availability of qualified night staff to ensure people remained safe at night.

• People received their medicines as prescribed as safe medicines management systems were being used.

• Incidents, accidents and complaints were investigated and actions were taken to prevent recurrence. Staff were given opportunities to reflect and share good practices.

• Effective infection control systems and regular servicing and maintenance checks of equipment and the premises were regularly carried out.

• People's care and support needs were assessed. Their care plans provided staff with the information they needed to support people. Staff encouraged people to make decisions about their care and have control of their lives.

• People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

• People’s individual risks were known and managed well by staff. Health care professionals provided positive feedback about the care and support people received.

• People were provided with a nutritious diet and drinks. They complimented the choice of foods. One person said, “I look forward to my food. I usually eat what’s on.”

• A new acting manager was in post. They were making significant progress in implementing new systems to improve the quality of care being provided. However more time was needed for systems and arrangements to be fully implemented and evaluated, such as further developing the activities programme to ensure people’s personal social and recreational needs were being fully met.

• Staff, people, relatives and other stakeholders praised the support and professionalism of the manager and felt confident in their vision, values and abilities.

The service met the characteristics of Good in four key questions and Requires Improvement in the key question ‘Is the service Well-led?’

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

Rating at last inspection: Requires Improvement (Last report was published on 8 May 2018). The overall rating for the service has improved from Requires Improvement to Good.

Following the last inspection, we asked the provider to complete an action plan to show us what they would do to meet the regulatory requirements and by when to improve the key questions, ‘Is the service safe and well-led?’ to at least Good.

We met with the provider on 5 September 2018 who told us about their action plans to improve people’s care records and the governance and monitoring of the home.

Why we inspected: We inspected this service as part of our ongoing Adult Social Care inspection programme. This was a planned inspection based on the previous Requires Improvement rating. We followed up on progress against agreed action plans, to address the breach of regulation found at our previous inspection. Previous CQC inspection reports, ratings and the time since the last inspection were also taken into consideration.

We last inspected in March 2017 and found that the provider was not meeting a number of the Health and Social Care Act 2008 regulations. This service has been in Special Measures. Services that are in Special Measures are kept under review and are inspected again within six months of the published report. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that sufficient improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Following our inspection in March 2017 we required the provider to carry out a monthly audit of the management of people’s medicines, equipment used to support people; the fire safety of the home, staff development, people’s care records and the governance of the home. The provider was required to send the Commission a monthly written report of the results of each audit and any actions taken. Since imposing the condition, CQC has been monitoring the provider’s monthly reports and progress. At this inspection in February 2018, we followed up on their actions and found many improvements had been made, however some further progress was still required to ensure people received effective care and to ensure the home was well run.

There was no registered manager in post as required by their conditions of registration. However a new manager had been employed and was in the process of applying to be registered with CQC. 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.

Whilst we found improvements had been made in the areas we had identified as requiring improvement, we found some ongoing shortfalls in the recording of the management of people’s risks. Further development of records relating to staff professional development and the monitoring of their advance training requirements to support people with complex needs were required. These shortfalls had not all been identified by the provider’s internal quality monitoring systems and further improvement was needed to ensure shortfalls would always be identified.

We will continue to ask the provider to undertake regular audits in relation to people’s care records and staff development and to send a monthly report to the Commission detailing the outcome and improvements made.

Significant improvement had been made to the home’s environment, the fire safety systems and the equipment used to support people. People enjoyed a home which was safe, clean and homely. People received care and support which was responsive to their needs. Staff were aware of people’s likes, dislikes and support needs. Improvements had been made to the recording of the management of people’s care. Detailed mental capacity assessments and best interest decisions had been recorded to protect people’s human rights.

People were supported by an established staff team who were familiar with their needs. Improvements had been made to the management of people’s medicines. Staff had been trained in their role and told us they felt supported by the new manager. Plans were in place for staff to receive additional training.

Staff were aware of their responsibilities to report any concerns of abuse or harm. Accident, incidents, concerns and complaints were reported and investigated into. People’s health care needs were monitored and any changes in their health or well-being had prompted a referral to their GP or other health care professionals.

A new manager was in post which had provided the home with stability. The manager was working with the provider to improve the home’s environment and the systems to monitor the running of the home. Quality assurance and communication systems were being implemented and reviewed to improve the quality of the service.

We found a continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

There was no registered manager in place as required by their conditions of registration. 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. However a manager was in place who had recently submitted an application to CQC to become the home’s registered manager.

We last inspected in July 2016 and found that the provider was not meeting a number of the regulations. Following our inspection the provider sent as an action plan of the actions they would take to meet the legal requirements. During this inspection we found some improvements had been made, however further improvement was still required to ensure people received safe and effective care and the home was well run.

People and their relatives were positive about the care they received and the meals they received. They told us staff were kind and looked after people well. People were referred to other health care professionals when their needs had changed. A range of activities were available in the home however people’s individual social and recreational well-being needs were not always met.

People’s care needs were mainly managed well and recorded. However, more detailed guidance was needed to assist staff with the management of people’s risks. Some pieces of equipment used to support people were not fit for purpose and alternative strategies had not been identified. People and their relatives had been involved in their care planning, although processes were not in place for relatives to lawfully sign for people’s care plan and associated records.

There was adequate recruitment systems in place to ensure staff had been suitably checked before they started to support people. People were supported by sufficient numbers of staff although the staffing levels of non-care staff at the weekends and in the evenings were variable, however we found no impact on people. The provider and manager did not always have a clear understanding of the skills and training needs of staff. Staff told us they felt supported but did not always have effective private meetings with their managers to discuss their personal development and objectives.

The manager had investigated and responded to complaints but had not always recorded the details and outcomes of their investigation. The provider had implemented a series of auditing tools to monitor the quality of the service being delivered, however the actions required was not clear when concerns had been found.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of this report.

The overall rating for this service is ‘Requires Improvement’. However we are placing this service in ‘special measures’. We do this when services have been rated ‘inadequate’ in any key question over two consecutive comprehensive inspections. The ‘inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate actions to propose 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 care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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 no registered manager was in place as required by their conditions of registration. 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. However a manager was in place who had recently submitted an application to CQC to become the home’s registered manager.

People and their relatives were mainly positive about the care they received however we found people’s safety and well-being was compromised in a number of areas.

People’s care records were generally up to date; however they did not always provide staff with relevant and detailed information about their personal histories and social interests. People’s individual support requirements in the event of a fire had not been thoroughly assessed. The risks associated with their care had been assessed and regularly reviewed but recommendations to monitor some people further were not always implemented. People’s medicines were managed and stored well. People were given their medicines on time however there were some inconsistencies in the recording of when people had received their medicines.

People’s personal interests and social needs were not always met. The decoration of the home did not support people living with dementia. The home had not been adequately maintained, although plans were in place to refurbish the home. People’s mental capacity to make significant decisions had not been thoroughly assessed or recorded, although some staff knew people well enough to understand their preferences. Records of best interest decisions made on behalf of people were not in place.

On occasions there were not enough staff to meet people’s needs. People were not always being effectively supervised. The manager had not always explored the employment history of new staff to ensure people were being cared for by staff who were of good character. Staff were not consistently trained or supported to carry out their role.

People were supported by staff who were kind and compassionate and knew people well. They understood their responsibility to safeguard people and report any concerns. People enjoyed the meals provided. Those who had specific dietary needs were catered for.

Tools were being used to monitor the service being delivered, however there were not records of the actions that need to be taken to address any identified shortfalls. The provider visited the home regularly and provided support. Information and significant events were not consistently shared with CQC as required by law.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Care Quality Commission (Registration) Regulation 2009. You can see what actions we told the provider to take at the back of the full version of this report.

As part of this inspection we spoke with six people who use the service, two visitors, the registered manager, five care staff and two other staff involved in the provision of the service to people. We also reviewed records relating to the management of the home which included, four care plans, daily care records, accident and incident records, quality assurance systems and staff rotas. Concerns had been raised with us prior to the inspection about staffing levels impacting on the quality of care, people's health and well-being being put at risk due to lack of food, poor continence and increasing falls. We found although staffing levels had reduced so had the number of people living in the home from 40 to 27. The provider had strategies in place for people at risk of malnutrition, incontinence and falls.

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

Is the service safe?

People were safe because emergency procedures were in place should they be needed to protect them from harm. Where people needed help or support to evacuate the building this had been identified. Emergency plans provided staff with information about how to respond to emergencies and keep people safe.

Accidents and incidents were being monitored for any trends which impacted on people's safety. Where necessary the appropriate action was taken to prevent these happening again such as referrals to health professionals to investigate their mental or physical health or providing equipment to safeguard people from falls. This meant the provider was taking action to keep people safe.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications needed to be submitted proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

People were safe because staff knew what to do when safeguarding concerns were raised and they followed policies and procedures. People understood what keeping safe meant and one person told us, 'I feel safe, life is good if I am left alone by others living here.' A visitor said, 'I feel people are safe'.

People were safe because staffing levels were assessed and monitored to ensure they were sufficient to meet their identified needs. A visitor told us, "Staff are always busy but they come straight away if you need them." People told us, "Staff are good fun", "I have no complaints about anybody".

Is the service effective?

People received an effective service because staff had a good understanding of their needs. People's individual needs, choices and preferences were reflected in their care plans. Visitors told us, "the care is second to none", "everyone knows the patients here, they are responsive to their needs", "staff are wonderfully patient".

People, especially those with complex needs, were effectively assessed to identify the risks associated with nutrition and hydration. People had access to dietary and nutritional specialists where needed. A choice of suitable and nutritious food and drinks were provided in sufficient quantities. People told us, "food is excellent', 'food is lovely" and staff said, "I never hear complaints about food", "plenty of food and snacks around people help themselves".

People's health was regularly monitored to identify any changes that might require additional support or intervention. Referrals were quickly made to health services when people's needs changed.

Is the service caring?

People received a service which was caring because staff knew the people they were caring for and supporting, including their preferences and personal histories. Staff showed concern for people's well-being. Staff were observed taking time to communicate with people sensitively and in a meaningful way.

As people's needs changed, staff knew how to manage their care appropriately in line with their choices and wishes. A member of staff commented, "We work well as a team.' We observed staff being attentive to people and responding to them kindly and patiently. A visitor told us, 'Staff are excellent, they have wonderful patience, treat people wonderfully.'

Is the service responsive?

A responsive service was provided because people had their individual needs regularly assessed and met. They received support and care when they needed it. A visitor said, "Staff are always busy but they come straight away if you need them."

People had access to activities that were important and relevant to them. We observed them enjoying a singer entertaining them. Individual as well as group activities were planned so that everyone could be involved in activities they enjoyed.

We observed visitors spending time with people and choosing where to spend time with them. People and their relatives knew how to make a complaint. A visitor told us, 'On the odd occasion I have raised a concern she (the registered manager) has acted straight away.'

Is the service well led?

The service is well led because the provider actively seeks the views of people, others important to them and staff to assess the quality of the service provided. They listen to people's feedback and take action to improve the service as a result. The providers had a range of quality assurance tools and audits in place to assess and monitor the service. This meant the robust quality assurance and governance systems were used to drive continuous improvement.

Staff understood what was required of them. They understood their roles and responsibilities. Visitors commented, "Very good staff and management", "We are kept well informed."

We were unable to ask people about their views of living in the home because people had a diagnosis of dementia and this limited their ability to verbally communicate. However, we observed staff interaction with people throughout our visit, spoke with six members of staff and looked at six people's care records.

We found the compliance action set in November 2013 was met. We observed some people take part in a singing activity with an external entertainer and staff spending one-to-one time with other people talking, reading or giving hand massages. People's care records had been updated to reflect their needs and wishes in relation to daytime activities. People's care records also detailed what activities they had taken part in each day.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location. The cancellation of this manager was being processed at the time of the inspection.

Our inspection of 5 June 2013 found that up-to-date information for staff to follow to ensure people's safety and welfare was not always recorded in care records. People who were not able to participate in activities were not always given one-to-one time with staff to meet their social and emotional needs. The provider told us that care plans for people would be reviewed and updated to reflect each individual's needs. The provider told us that these changes would be implemented by 30 September 2013.

We were unable to ask people about their views of living in the home because people had a diagnosis of dementia and this reduced their ability to verbally communicate. However, we observed people in one of the lounges throughout the day and in the dining room during the lunchtime period.

We found that care records had been updated since our visit in June 2013 to accurately reflect people's needs in relation to their physical health and personal care needs. However, we found that peoples' needs in relation to their daytime activities had not been fully planned or delivered.

We were unable to ask most people about their views of living in the home because people had a diagnosis of dementia and as a result had some communication difficulties. However, we observed that staff understood the best way to communicate with people and were able to support people to make choices about their daily living. People who could express their views told us, 'they (staff) look after me, they are good here' and 'I can get up and go to bed when I want to'.

We looked at the care plans for seven people and saw that these were regularly reviewed. However, not all had been sufficiently updated to reflect people's current needs. Communal areas were crowded and we observed occasions during our visit when there were not enough seats for people. We saw that activities were provided for people and those who could participate seemed to enjoy them. People who were not able to participate were not always given one-to-one time with staff to meet their social and emotional needs.

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

During our visit we spoke with four people living in the home and spent time observing people in the communal areas. People we spoke with told us they were happy living in the home and were able to make choices about their daily living. We saw that staff interactions were respectful and were at the pace of the person they were working with. A relative we spoke with told us 'I am happy with the home, it is not too regimented'.

Care plans were personalised to each individual's needs and detailed how staff should work with people to meet those needs. Risk assessments had been completed where necessary and all care records were reviewed monthly. Staff were appropriately trained and showed good knowledge of the people they cared for. One person told us 'staff are very good, I have no complaints'.

Consent for care and treatment was consistently sought from people or their relatives who acted on their behalf. Care was provided in an environment that was safe, well maintained and met people's needs.