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 assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.
 

This service scored 81 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Accidents and incidents were recorded and reviewed so any trends or patterns could be identified. These records were evaluated regularly by a behaviour analysist and action taken to mitigate risk and improve people’s experiences. Analyses of records showed incidents had been reduced as a result of how people had been supported. An external professional told us, “Staff at The Pines have worked with the professionals on the advice that has been given and this has shown an improvement in the individual.”

There were effective mechanisms for sharing lessons learned. Following any incident staff had a debrief with a manager to identify what had worked well and what could have been done differently. A member of staff explained, “We log any incident, have a debrief, (it is a) process of reflection, what happened, why, is there something more we can do. It’s a good way of following up, analytical thinking about the why to give some insight.”

Staff had clear information to support them when identifying what needed to be recorded as an incident. This meant there was a consistent approach to recording which underpinned strong data collection.

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.

The service communicated with other agencies to help ensure continuity of care. Staff made timely and appropriate referrals to relevant health professionals when additional assessments or interventions were required.

The service held regular meetings with the wider multi-agency team to review people’s needs to ensure care and support continued to reflect people’s assessed needs. This collaborative approach supported consistent, person-centred care delivery. An external professional commented, “Complex medical issues often surround the residents, with many teams involved. The management are skillful at communicating with medical teams in primary and secondary care as well as families, all in the resident’s best interests.”
 

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 Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

Mental capacity assessments were completed to evidence when people lacked capacity to make decisions. There was no evidence people had been involved in capacity assessments or supported to understand the decisions being made. Following the assessment the provider developed a template for recording capacity assessments and best interest decisions. This included prompts for staff to evidence how people had been supported to be involved in the process.

Necessary Deprivation of Liberty Safeguard (DoLS) applications had been made when required. Restrictive practices were monitored to help ensure they remained proportionate, in the person’s best interest and the least restrictive option. A physical intervention training manager reviewed all restrictive practices annually.

Staff had completed training in safeguarding and the MCA. They understood their responsibilities under safeguarding and reported any safety concerns to management. Staff were confident any concerns they raised would be dealt with but were aware how to escalate issues outside of the organisation if needed. The registered manager had reported safeguarding incidents appropriately.
 

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.

People had detailed care plans and risk assessments to guide staff on how they could mitigate any identified risk. Care was provided safely while enabling people to do the things that mattered to them. Staff had access to advice from a Positive Behaviour Support team who were able to develop strategies bespoke to people’s needs with the aim of reducing risks over time.
 

One person had been identified as being at risk of choking. A referral to the speech and language team had been made. Risk assessments had been updated and there was clear guidance for staff on how to mitigate the risk.

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

Checks of utilities and equipment were regularly carried out by external contractors. Staff completed weekly and monthly checks such as vehicle checks and fire safety checks. Following a visit from local fire officers some areas for improvement had been identified. Records showed these had been promptly addressed.

Some areas of the service were tired and in need of updating. This had been identified in audits and an action plan developed to monitor the progress of improvements.
 

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

New staff were recruited safely and completed an induction before starting work at The Pines. There were sufficient staff to meet people’s needs and enable them to take part in any pastimes or hobbies they enjoyed.

Agency staff were sometimes used to cover gaps in the rota. The service had the information they needed to help ensure agency staff had the necessary skills and experience to support people living at The Pines. The same agency staff were used to help provide consistent care. The registered manager told us agency staff would always work as the second member of staff so there was always an experienced, permanent member of staff leading the shift. Shift patterns were flexible so people could take part in activities when they wanted to.

There was an emphasis on the importance of providing staff with relevant skills to enable them to support people in line with their individual needs.

Green Light developed bespoke physical intervention training to ensure staff had the skills necessary to meet people’s needs. The training had been accredited by the British Institute of Learning Disabilities (BILD). In addition, they had provided training for supporting people with Obsessive Compulsive Disorder and Intensive Interaction, a recognised technique for supporting communication with people who do not use words.

A training matrix showed staff had completed training in supporting people with a learning disability and autistic people. Arrangements were being made, at the time of the assssment, to provide the preferred and recommended training on learning disability and autism for health and social care staff across the organisation.

A dedicated Positive Behaviour Support (PBS) team structured and delivered PBS training across the organisation.

Staff told us the training provided was good and gave them the skills they needed to support people safely. One member of staff told us training was, “So good, interesting and engaging.” Staff received regular supervision and yearly appraisals, they told us they were well supported.
 

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 environment was clean and tidy. Staff received training and were provided with appropriate protective clothing, such as gloves and aprons to use when carrying out personal care.
 

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.

Some people had medicines prescribed to be used, ‘as required’ (PRN). There were protocols to guide staff on the use of PRN medicines. Managers and staff monitored the impact of medicines on people and shared this information with health professionals and relatives which ensured people’s treatment met their needs.

Staff had received training in the administration of medicines and were assessed as competent to provide support in this area. Following any medicine errors staff competencies were reassessed. People’s medicines were stored in their flats to enable staff to support them in privacy when medicines were being administered.