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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulations in relation to safe care and treatment and safe environments. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

At our previous inspection, the provider did not consistently demonstrate a proactive and positive safety culture. Since then, significant improvements have been made. Oversight had been strengthened through the implementation of more robust systems and processes, supporting the development of a positive learning culture. Lessons arising from accidents and incidents were now consistently identified, communicated, and embedded into everyday practice.

This approach enabled staff to reflect on events, understand how to reduce the risk of recurrence, and drive continuous improvements in the safety and quality of care.

The provider now routinely reviewed accidents and incidents and analysed people’s ABC charts (used to examine behaviours by recording antecedents, behaviours, and consequences) to gain a deeper understanding of people’s experiences. This enhanced oversight allowed the management team to respond promptly, updating care plans and risk assessments when required, and ensure that learning was translated into meaningful actions to keep people safe.

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 management team completed pre-admission assessments for people wishing to use the service to ensure their needs could be met. Relatives and health and social care professionals were consulted to ensure people’s needs were known and understood.

Following admission, people were supported with 28-day care plans, which guided staff on how to provide appropriate support during the initial period. These plans included key information about each person, such as the level of staffing they required, and whether people could express their needs or if staff needed to anticipate them.

The admission information and 28-day care plans helped to prioritise people’s safety and ensure continuity of care throughout their journey with the service.

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.

People said they felt safe at the service and staff treated them well. A relative told us, “[Person’s] a lot safer here than the last place they were in. They really care here. I’m treated like family too as I come most days.”

Systems were in place to safeguard people from the risk of harm, abuse and discrimination. The provider had a clear and accessible safeguarding policy, and staff had received appropriate training to ensure they understood their responsibilities.

Staff demonstrated a clear understanding of safeguarding principles and were confident in identifying potential signs of abuse or neglect. They were knowledgeable about how to raise concerns, internally and externally, in line with the provider's policy.

The provider engaged with people and healthcare partners to gain a clear understanding of what safety meant to those using the service and how best to support them. Care plans and risk assessments contained the information staff needed to keep people safe. The provider worked well with the local authority, and safeguarding referrals were made promptly.

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.

Since the last inspection, significant improvements had been made to the way risk was managed at the service. The provider had strengthened their approach to risk management, ensuring care records were more detailed, up to date, and person-centred.

Personal Emergency Evacuation Plans (PEEPs) were in place for all the people using the service. These included a scoring system to identify each person’s specific evacuation needs, the number of staff required, any necessary equipment, and clear guidance on how to support them safely in the event of an emergency.

Risks to people were effectively managed, enabling them to live meaningful lives in line with their choices and preferences. Staff understood people’s needs and could describe specific risks, as well as the measures in place to manage these safely. A comprehensive range of risk assessments guided staff practice, including those related to falls prevention and supporting individuals who may become distressed.

We observed staff supporting people with moving and transferring in a safe, respectful, and person-centred manner, always working at the person’s pace. Relatives confirmed that their family members were supported safely and that appropriate equipment was used. One relative told us, “I’ve no worries about how they move [person].”

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

Since our last inspection, improvements had been made to the safety and maintenance of the premises. Wardrobes were securely fixed to walls, radiators were fitted with protective covers, and window restrictors had been installed to reduce the risk of falls. These measures helped ensure people were supported in a safe environment that was designed and adapted to meet their needs.

However, some issues still required attention. We identified a wardrobe with items stored on top, which could fall and pose a risk to anyone attempting to retrieve them. We raised this with the provider, who acted immediately to ensure the items were safely stored elsewhere.

A person who used the stairs had a risk assessment for this. However, to descend, they had to lean forwards and downwards to open a child’s stairgate at the bottom. This put them, and staff at risk of falling. We reported this to the provider who arranged to have the child’s stairgate replaced with a full-size one. This was done by the time we returned for the 2nd day of our inspection.

Although parts of the premises had been refurbished and improved, some areas of décor remained worn and damaged. We observed chipped paintwork, damaged wallpaper, and a worn carpet on the upstairs landing. The provider acknowledged these issues and advised they would be addressed as part of the service’s ongoing improvement plan.

Bedrooms were fitted with push-to-open doors without locks. This meant people could not lock their doors for privacy or to prevent others entering without their consent. We discussed this with the provider, who agreed to consult with people about their preferences, record their decisions, and install locks where requested. The provider said best interest decisions would be made for people who needed these.

The provider had systems in place to monitor the safety and upkeep of the premises and engaged appropriately qualified professionals where necessary to carry out required environmental and equipment servicing and checks.

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.

At the last inspection, the provider did not always ensure there were enough qualified, skilled and experienced staff to support people safely. Since the last inspection, improvements have been made to staffing arrangements.

Staff received training appropriate to their roles, ensuring they had the skills and knowledge to support people safely and effectively. They were safely recruited to help ensure they were suitable to work with people who use care services.

There were sufficient staff to support people safely. A person said, “The staff are very good and friendly. There’s always enough on [duty].” Relatives told us they were satisfied with staffing levels at the service, including during the evening and at weekends. A relative commented, “There is enough staff and the residents get the attention they need. If the staff are busy, it can take longer for the front door to be answered but we do understand why that is.”

The staff team was established with some staff having been employed by the previous provider before the service changed hands in February 2024. This meant people had continuity of care from staff they knew who understood their needs. In addition, the provider did not use agency staff, so people were always supported by staff who were familiar to them.

The service used a ‘dependency tool’ to calculate people’s care and support needs and work out how many staff were required on each shift. This was aligned with the local authority’s‘staffing analysis tool’ and helped to ensure the right number of staff were always available.

People and relatives told us staff came quickly if a person range their call bell. A person said, “They come quite quickly if I ring, and it’s the same at night too.” A relative told us, “It’s very safe, the staff are there in an instant [if a call bell is rung]. It’s far superior to other care homes [person] has been in.

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 provider had effective systems and processes in place to assess and manage infection prevention and control. An infection prevention and control policy was in place. Personal protective equipment (PPE) such as gloves and aprons was readily available, and hand sanitising stations were fully stocked. Staff had completed relevant training and demonstrated a clear understanding of the measures in place to reduce infection risks.

The premises were clean and fresh throughout. People’s rooms were tidy and well presented. People and relatives spoke positively about the cleanliness of the service. A person said, “My room’s kept very nice and clean.” A relative told us, “The place looks fine and the staff are excellent. There are no nasty smells in this home.”

People told us they had regular access to showers. A person said, “The staff are shower mad and encourage me to have one quite often.” A relative commented, “[Person] has a shower most days and the laundry does a good job with [person’s] clothes.”

The provider conducted regular infection control checks and audits to ensure people were protected from the risk of infection. The service had a food hygiene rating of 5 (the highest mark achievable) and scored 95% at their latest local authority IPC inspection. This was further evidence of the service meeting it’s IPC obligations.
 

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.

At the last inspection, the provider did not always ensure that medicines and treatments were safe and met people’s needs. Since the last inspection, significant improvements have been made. The provider had ensured comprehensive PRN protocols were in place for all people who require as-needed medication. These protocols clearly outline when PRN medication should be offered, the dosage, the symptoms that may indicate the medicine needed, and when further medical advice should be sought.

Systems were in place to ensure medicines were ordered, received, stored, administered and disposed of safely and in line with current guidance. Only staff who had completed medicines training were authorised to administer medicines. Medicines administration records (MARs) were accurately completed with no missing signatures. Monthly medicines audits were carried out to monitor compliance and identify any areas for improvement.

Controlled drugs were stored securely. A running balance was maintained, and stock levels checks were completed in line with local policies. The medicines fridge contained only medicines, was locked and within the required range. However, we noted the room temperature where medicines were being stored was recorded slightly above the recommended temperature. We brought this to the attention of the provider who agreed to take appropriate action to ensure medicines were stored within safe temperature parameters.

Relatives spoke positively about medicine management. People told us the staff waited while they took their medicines. A person said, “I have a lot of tablets to swallow, and [staff] wait by me.” A relative said their family member had time-specific medication and ‘always took them on time’.