The Pines

Updated 4 March 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 17 March 2021 and was announced.

Updated 4 March 2022

The Pines is a residential care home registered to provide personal and nursing care for up to 11 people living with dementia or a physical disability. There were nine people using the service at the time of our inspection.

People’s experience of using this service and what we found

The provider failed to involve some people, their relatives and professionals where relevant and had not maintained a record of decisions made in their best interests, in line with the Mental Capacity Act 2005. The provider had not identified an issue that we found at this inspection and taken action to improve in a timely manner.

The service had a positive culture, where people and staff told us they felt the provider cared about their opinions. The registered manager had knowledge about people living at the home and made sure they kept staff updated about any changes to people’s needs. They encouraged and empowered people and their relatives to be involved in service improvements. The provider had worked in partnership with a range of social and healthcare professionals.

People gave us positive feedback about their safety and told us staff treated them well. The registered manager and staff understood what abuse was, the types of abuse and the signs to look for. Staff completed risk assessments for every person and they were up to date with clear guidance for staff to reduce risks. There were enough staff on duty to support people safely and in a timely manner. Staffing levels were consistently maintained to meet the assessed needs of people. The provider carried out comprehensive background checks of staff before they started work. Medicines were managed safely. Staff kept the premises clean and safe. The provider had a system to manage accidents and incidents to reduce the likelihood of them happening again.

Staff carried out pre-admission assessments of each person’s needs to see if the service was suitable and to determine the level of support they required. Staff received appropriate support through training, supervision and appraisal to ensure they could meet people’s needs. Staff told us they felt supported and could approach the registered manager, at any time for support. Staff assessed people’s nutritional needs and supported them to have a balanced diet. People told us they had enough to eat and drink. The provider had strong links and worked with local healthcare professionals in a timely manner. The provider met people’s needs by suitable adaptation and design of the premises. Staff completed health action plans for everyone who used the service and monitored their healthcare appointments.

Staff asked for people’s consent, where they had the capacity to consent to their care. Some people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff showed an understanding of equality and diversity. They supported people with their spiritual needs where requested.

Staff involved people or their relatives in the assessment, planning and review of their care. Staff respected people’s choices and preferences. People told us staff treated them with dignity, and their privacy was respected.

Staff recognised people’s need for stimulation and supported them to follow their interests and take part in activities. People responded positively to these activities. Staff had developed care plans for people based upon their assessed needs. Care plans were reviewed on a regular basis and reflective of people’s current needs. People told us they knew how to make a complaint and would do so if necessary. The provider had a clear policy and procedure for managing complaints. The provider had a policy and procedure to provide end-of-life support to people.

Rating at last inspection – The last rating for this service was good (report published on 8 June 2017).

Why we inspected - This was a planned inspection based on the rating at the last inspection.

Enforcement – We have identified one breach of regulation. The provider had not always worked within the principles of Mental Capacity Act (MCA). Please see the action we have told the provider to take at the end of this report.

Follow up - We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk