Pine View 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. This is the first assessment for this newly registered service. This key question has been rated 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and safe environments.

This service scored 41 (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. Risks to people were not consistently used to learn and improve. For example, oversight processes were not yet embedded into practice to allow the provider to effectively mitigate risk or monitor for themes and trends. We found the management team were open and transparent and wanted to drive improvement at the service.

The provider told us pre-admission assessments were carried out before new people were admitted to the home to ensure they could meet the individual’s needs. However, we found there were gaps in the information recorded in people’s care records which could impact on continuity of care and safe transitions. We received positive feedback from a visiting healthcare professional who told us, “Staff ensure visits are prepared for when we arrive.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Most people told us they felt safe living at Pine View Care Home. When asked if they felt safe 1 person said, “Most definitely.” However, 1 person told us, “I don’t like it here, I never feel safe.” We identified the provider while the provider made safeguarding referrals where appropriate they did not have oversight records in place for the referrals to record actions and analysis.

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. Effective systems to provide robust oversight of accidents and incidents were not fully embedded. Care records required more detail in some areas of support and for information to be updated across the home. For example, 1 person’s Personal Emergency Evacuation Plan (PEEP) failed to provide detailed guidance on how staff were to support the person during an emergency evacuation.

Records of support completed by staff were not always regular or detailed. We identified records demonstrated longer gaps between support than that advised in people’s care plans. For example, 1 person’s care plan identified they should be repositioned 2 hourly but there were numerous occasions where the gap in the documentation was longer than this. This put the person at risk of damage to their skin.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We identified 1 wardrobe, and a large set of drawers were not secured to the wall. This put people at risk of injury from falling furniture. The communal garden was not safe for people to use. We identified large bottles of detergent, broken bricks and furniture discarded, a broken handrail up the external steps and an exposed pond with water present. Systems such as fire, electrics and gas were maintained and serviced.

The provider did not always make sure there were enough qualified, skilled and experienced staff. We were not assured there were enough staff working in the service to ensure they were always available to keep people safe and provide timely support where required. During our assessment only 2 staff members were allocated during the day, with 1 additional staff member arriving later to support a person who needed continuous support. However, there were multiple people who required the assistance of 2 staff members to support them. This meant at times when any of these people were being supported, the rest of the people were not supervised sufficiently to ensure they remained safe. Care staff were also required to complete additional duties such as housekeeping. We received mixed feedback from people regarding the staffing levels at Pine View Care Home. One person told us, “Sometimes you are waiting, but most of the time they are equipped to help.” Another person said, “It depends on the day, some days are very busy, but I am never neglected here.”

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. We identified significant failings with the cleanliness and upkeep of people's living accommodation. Two mattresses were stained, and people’s beds had been made by staff with dirty bed lining. Three commodes were visibly soiled and dirty. Paintwork to handrails throughout the service were chipped exposing porous wood meaning they could not be cleaned effectively. Limescale was found on several taps around the service. Limescale deposits can be a breeding ground for dangerous bacteria including Legionella bacteria which causes Legionnaires' disease. Records referenced shower-head descaling but did not record any descaling of tap outlets.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Where people were supported with PRN (as required) medicines there was not always guidance in place to support this. Where PRN protocols were in place they were not always person centred. Staff did not consistently record the outcome of PRN administration. This meant the effectiveness of the medicine could not always be reviewed. We identified where a person’s PRN medicine administration had not been effective there was no evidence what staff had done regarding this.