Pine Tree Court Care Home

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 assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incidents and accidents had not been effectively and robustly reflected upon and used to drive improvement. For example, there were several incidents reported where people had been aggressive towards staff, however, no actions were taken to ensure staff had the skills and knowledge to de-escalate behaviours and promote positive outcomes for people who were distressed. There was a lack of oversight and monitoring of incidents. Information was not clearly recorded or legible and it was not clear what action, if any, was taken following accidents and incidents. This meant opportunities to learn lessons from incidents and take appropriate action was missed. Staff we spoke to were unclear about how to support people with distressed behaviours. One staff member told us, “When people make certain noises, I inform the nurse or manager.”

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.

At the time of the inspection, the managers had made significant improvements to their systems and processes, including how they worked with external organisations when people needed additional staffing support and when they wished to move from the service. The managers were working with the local safeguarding teams, social workers and others to ensure people were safe. One relative told us, “The journey to here was fairly quick through the local authority and the dementia nurse. We had initial respite elsewhere and then here as this was the only local authority place. We live about an hour away.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Systems in place were not always effective at ensuring people were protected from abuse and neglect. Incidents were not reviewed, and safeguarding concerns were not always escalated appropriately. CQC was not always notified about safeguarding alerts by the service in line with legal requirements. We found staff were not always aware of the need to balance safety with positive risk taking, for example, staff were reluctant to provide people with access to the outside garden and did not feel confident escorting people with dementia outside in the community. We found staff did not appear confident in assessing people’s holistic needs. For example, one person had bed rest in the afternoons, but was not given access to a call bell. Staff had not thought about how the person may seek staff assistance while they were in bed. This was addressed by the managers following the inspection and a call bell was given to the person, who then successfully used it. Staff we spoke to were only able to recall one situation where something changed following a safeguarding incident which was the implementation of 1:1 support. One staff member told us, “When the person had inappropriate behaviours, I recorded on an ABC chart and completed an incident form. We now have 1:1 support in place for safety. The person now does activities with staff, so the safety of other people and staff is maintained.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Although people had risk assessments in place, policies had been implemented which were restrictive. For example, people were not permitted to have water jugs in their rooms. When we asked about this practice, the manager told us there was one person who frequently went into other people’s rooms and there was a risk they would drink water from other people’s water jugs. The manager was concerned this person may choke on the water. Their solution was to remove all the water jugs from people’s rooms. We expressed our concerns with this practice and the manager agreed to review this; however we were not made aware of any change to this practice after the inspection.

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

Fire drills were completed; however, the records did not indicate if these were done during the day or night or how many staff had attended. This meant the provider could not be assured all staff had taken part in drills. The provider had ensured regular safety checks had been completed on equipment. However, we found some rooms had outdated window restrictors and not all the pictures hanging on the walls were safely fixed putting people at risk of harm. We brought these concerns to the manager, and the window restrictors were updated the same day. We found the environment to be safe, staircases had gates on them at both ends, chemicals were locked away and care records were kept in a secure room behind the reception desk.

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.

We found staff had been recruited safely but had not received training appropriate to their role, the training they received was mainly e-learning and staff were not given competency assessments post training to determine their understanding of the subject and how they implement the training in their work. We found staff were not always confident and did not have the required skills and knowledge to always meet people’s needs. Training had not adequately prepared staff to support people who became distressed. We observed staff being more task orientated than person-centred. We found the service was no longer in breach of regulation regarding fit and proper persons employed. We found staffing levels to be good and there were enough staff to meet people’s needs during the inspection. Relatives told us they found staff were effective. One relative told us, “We are very pleased with the care, but the paperwork side hasn’t been followed through, or so we thought. However, when we met with the deputy manager the other day, we realised that things were happening.”

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.

We found the provider had made improvements to infection control practices since the last inspection and were no longer in breach of the regulation for safe care and treatment. We observed the premises to be clean and free of clutter. There were some malodours in the conservatory, but none in other areas of the service. Staff used appropriate infection control techniques, such as effective handwashing and used protective clothing when giving personal care. However, food labels in the kitchen storeroom were not in place, some areas of the kitchen storeroom were dusty and there were no opening dates on drinks available in the dining room. We addressed these concerns with the manager who took immediate action.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The service demonstrated clear scheduling of medicines rounds at set times with nurses, senior carers, and carers trained and authorised to administer medications. Records were largely paper based, with MARs (medication administration records) and protocols for medicines to be used ‘as required’ (PRN) stored securely in the nurses’ office. There was evidence of good practice with medication administration, PRN documentation, and safe disposal of medicines. Weekly GP visits, supported by monthly liaison with the GP surgery’s medical secretary, ensured timely reviews and escalation of medical concerns. Fridge and room temperatures were recorded, however, there were a few gaps,meaning staff were not always recording temperatures in line with their medicines policy. We saw evidence of regular audits taking place and there was a medicines policy to support with medicines management.Gaps meant medicines may degrade or become unsafe if stored outside required temperatures. For all medicine records, allergy statuses were consistently recorded, homely remedy protocols were in place and there was no evidence of missed doses of regular or time critical medicines. However, some inconsistencies and gaps were identified, for example fire-risk assessments for paraffin-based products were absent. Incorrect risk categorisation could undermine safety planning and fire risk requires evidence of mitigation for storage and safe use. The service had established systems for medicines management with clear leadership and processes in place. Staff demonstrated kindness, respect, and adherence to protocols during observed rounds. However, improvements were required in documentation accuracy, capacity and covert administration records, and controlled drug governanceto meet best practice standards and ensure safety. For example, some mental capacity assessments (MCA’s) lacked evidence they were included in the monthly care plan reviews to ensure they remained current. Decisions about medication administration—especially covert—should reflect current capacity; outdated MCAs mean people may be treated without lawful justification. We did not find evidence of multidisciplinary or best-interest discussions for each medication for people receiving covert medicines which is best practice. Disposal records were missing for returned controlled drugs (CD’s). Missing documentation increased the risk of diversion, theft and dosing errors.