Pine Tree Court Care Home

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

Requires improvement: This meant people’s needs were not always met.

The service was in breach of legal regulation in relation to person-centred care.

This service scored 62 (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 did not make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

We heard a person telling a staff member they were in pain. The member of staff did not respond in a person-centred way. Water jugs were found to be unavailable for people in their rooms and fresh water was not available for people in the communal living areas. This decision had been taken for the benefit of one person without considering the needs of others. The service was not supporting the local GP surgery with the roll-out of Covid-19 booster vaccines. The service referred to people in the daily notes in ways which were not person-centred and used terminology such as ‘person was fed’, and ‘person was put to bed’. There was no visible activity planner or calendar for the day, week or month and no schedule of activities. Relatives told us they had concerns about activity provision. One relative said, “[person] has been here two and a half years, and this is the first time I’ve seen an activity done. Lots of things should have been in place, such as activities.” People were not supported with meaningful activities, for example, one person with advanced dementia was assisted to sit at a table in front of a TV screen which was turned off. Nothing was placed on the table for them to engage with and they were sat facing away from others in front of a wall. The person then expressed distress, but staff only intervened with a view to stop the behaviour and not with an aim to understand why the person may be experiencing distress. The needs of people with a learning disability had not been taken into account. Staff had not received training in ‘Right Support, right care, right culture’ and the provider was unaware of the guidance. This meant people were at risk of receiving care which did not meet their needs. This was a breach of the regulation for person-centred care.

The provider understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The managers had been supporting a person who wished to move from the service to find a suitable placement in another county. The managers had clearly documented the person’s wishes in mental capacity assessments and showed they had conversations with them about the move and why the person felt the service was not the right place for them.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

There was appropriate signage in the service to identify different areas of the service, such as the dining room, lounge and toilets, however there was no accessible information for activities, calendars and menus. There was a staff board which showed pictures of the staff on shift for the day. Copies of the complaints policy and safeguarding policy were visible by the front door. We observed staff were not wearing name badges, and when this was brought up with the managers, they told us, “Name tags are something we are looking into. We're looking into different types of name badges. We haven't had name tags for at least 3 years. I will put on my action plan.”

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

Regular residents’ meetings took place where people were able to have a say in how the service was run. People told us they would speak with staff if there were any aspects of their support, they were unhappy about. People and relatives told us managers responded to any feedback positively and took immediate action. The service sought feedback from relatives through meetings and regular correspondence. Relatives were encouraged and observed coming in, to complete care plan reviews. People and relatives confirmed they knew how to complain but had not had to do so. One relative commented, “They are very good with falls. They will call and let us know that [relative] has fallen. We have had discussions regarding do not resuscitate (DNR) and have spoken with the nurse from the surgery. We think it is in the folder we went through with the deputy manager last week.”

The provider made sure that people could access the care, support and treatment they needed when they needed it.

People living at the service experienced equity in accessing the support they needed. Nurses and managers ensured everyone was able to access the same specialist services when required.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Staff were not trained and supported to use de-escalation techniques and dementia specific approaches which meant people were not given care tailored to their needs. While people’s physical health needs were met to a good standard, their emotional and psychological needs were not always met consistently. For example, people had not been supported to leave the service to go for walks, attend external outings or sit in the garden over the summer months. The service had a policy whereby it stated people would have access to a mini-bus between May-September, however the managers informed us this had not happened this year. However, after the on-site inspection managers had made significant advancements in this area and between the time of the on-site inspection to October 2025, the service had supported people to go on multiple outings.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Each person’s care record had a section on their wishes for end-of-life care. The service had adopted a ‘Living Eulogy’ section which included important information they wanted people to know about their life.