Pinewood Residential 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

We identified 2 breaches of the legal regulations. People were not always protected from risks associated with their environment. We found hazardous chemicals were not stored safely, windows were not restricted in line with guidance, doors that should be secured were left open and people were not safe from the risk of fire. Cleaning checks and records were in place. However, these had not always been completed and there was a lack of oversight in place to ensure the service was kept clean and free from infections. We made a recommendation about this. Care plans and risk assessments were not always in place or reviewed and updated regularly. Where monitoring records were in place these were not always completed. Medicines were not always managed safely. Medicines audits had failed to identify that medicated creams and powders had been left out in people’s rooms, were not always dated when opened and staff had not received training to apply medicated creams. People’s allergies had not always been recorded in their care records. We were not assured people were cared for by staff that had received mandatory training or training updates regularly. Staff were not always supported with regular supervisions and appraisal. However, people told us they felt safe, staff knew how to care for them well and other risks to people such as, people at risk of falling or not having adequate nutrition and hydration were being managed well and advice was being sought when needed. There were enough staff available to care for people and staff were recruited safely.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us they felt safe living at the service and knew who to go to if they felt unsafe. One person said, “We are very well looked after here. They will do anything for you. They [staff] are very willing to help, very accommodating. I would speak to the boss if there was anything seriously wrong.” A relative commented, “My sister is absolutely safe, so far everything is fine. If I had any concerns about her safety I would talk to the senior staff or the manager.”

People were protected from the risk of abuse and harm because staff understood what abuse was and knew what to look out for. Staff described what they would do if they thought someone was being abused or mis-treated and who they would report it to. One staff member told us, “I would go right to [registered manager’s name] or one of the seniors and they would certainly hear. I would phone safeguarding if no action was taken and if I thought it was physical abuse or something like that, I would phone the police.” The registered manager described the process in place to record, report and investigate allegations of abuse. They told us staff received safeguarding training every 2 years and they regularly discuss safeguarding with staff during staff supervisions.

During the site visit we observed people were comfortable in staffs’ presence and we observed kind caring interactions. Information was displayed around the service guiding people, relatives and staff about how to report concerns.

The providers staff training records did not demonstrate that all staff had received safeguarding training every 2 years as described by the registered manager. For example, records showed 4 staff had not received safeguarding training. In addition, 6 staff, including the registered manager and provider, had not received a training update since 2020. This potentially put people at risk as staff may not have sufficient knowledge to recognise abuse and what action they needed to take. Policies and procedures were in place to guide staff on what action they needed to take if they suspected abuse or felt unsafe. Processes were in place to record, investigate and refer safeguarding incidents to the local authority and report to the CQC.

People told us staff knew them well, how to care for them and meet their needs. People told us about what staff did to protect their skin and how they supported them to move safely. One person said, “They do everything safely and do it properly and if one can’t manage, they call another member of staff to help them.” Relatives described what staff did to manage risks associated with their relative’s care. For example, one relative told us, “He [the person] kept falling at home but now he is safe, he has had no accidents. They use a stand aid hoist which the staff all know how to use, and they make sure he doesn’t have any sores, his well-being is paramount.” Whilst people and relatives were positive, we found elements of care provision that placed them at risk.

The registered manager told us not all care plans, risk assessments and monitoring records for people living at the service were reviewed monthly. The registered manager told us they had recently introduced new care plan audits and checks following issues identified at a recent assessment at the sister service where they were also the registered manager. They told us this process would ensure all care records for each person living at the service would be reviewed monthly through a ‘resident of the day’ care review. Staff knew people well and were able to tell us about their care needs and how to mitigate risk. Staff were able to describe how they managed people’s skin to prevent skin damage, monitored and recorded peoples’ food and fluid to prevent weight loss and what action they took to prevent people falling.

During the assessment we observed staff supporting people safely in a kind and caring manner. People at risk of skin damage had appropriate pressure relieving equipment in place such as airwave mattresses and pressure relieving cushions. Sensor alarm mats were in place to alert staff where people had been assessed as at risk of falling. People at risk from not receiving enough to eat and drink were having their food and fluid intake monitored.

The processes and systems in place to manage potential risk of harm to people were not always effective. Care plans and risk assessments contained guidance for staff on how to manage or mitigate risk. However, whilst staff knew how to care for people and manage risk, some care plans and risk assessments were not always consistent across each section or reviewed and updated regularly. Where monitoring records were in place, such as for repositioning, these were not always completed consistently. Equipment was in place to mitigate the risk of harm such as, pressure relieving mattresses to reduce the risk of skin damage. However, people’s records did not always demonstrate that staff had been checking that mattresses were working correctly or were set on the correct settings. These concerns potentially put people at increased risk of avoidable harm and was a breach of regulations. People who were at risk from losing weight were being monitored and weighed regularly and advice had been sought from people’s GP and dietitian about how to help the person gain or maintain their weight. People at risk of falling were being monitored and appropriate action had been taken such as increased monitoring and using bed rails and sensor alarm mats to keep people safe.

Whilst people and their families did not raise any concerns about their living environment, certain aspects of the premises and environment did not meet the expected standards and did not protect people from the risk of harm. People commented the service, and their rooms, were cleaned regularly and were comfortable.

We discussed concerns we found with the safety of the environment with the registered manager and provider. The registered manager and provider agreed that systems and processes in place to protect people from the risk of harm associated with their environment were either not in place or completed effectively. For example, fire drills and weekly fire tests were not taking place and there were no formal auditing processes in place to check the safety of the environment. However, the registered manager and provider told us they would take immediate action to address the concerns we identified. Staff we spoke with did not raise any concerns about the safety of the environment. Some staff confirmed that fire drills did not happen at the service, and they did not know what they needed to do in the event of a fire or how to use the fire panel.

During our observation of the environment, we found windows throughout the service had not been fitted with suitably robust tamper proof restrictors to ensure compliance with health and safety legislation. This exposed people using the service to risk. We found hazardous chemicals in a room that was open and not secured by an adequate locking device. This was in a room next to a person identified by the provider as a person living with dementia that liked to walk around the service independently. This put this person and others at risk of harm from ingesting harmful chemicals. We found a radiator in the first-floor shower room did not have a cover fitted which put people at risk from burn injuries. We found various rooms throughout the service that should have been secured and locked, were left unlocked and/or staff had left their keys in the locks, including a boiler room and the medicines administration room.

The service did not have effective systems and processes in place to ensure people were protected from risks associated with their environment. The registered manager told us they did not complete environmental audits as part of the service governance. This meant the registered manager and provider had not identified that chemicals were not stored safely and doors that should be secured, were routinely being left open. Window restrictor audits in place had not identified the concerns we found in relation to the windows. Oversight of fire safety was not effective; no fire evacuation drills had been completed and audits had not identified PEEPs were not readily available in the emergency grab bag. The failure to effectively manage and mitigate risks, placed people and staff at an increased risk of avoidable harm and was a breach of regulations. During the assessment the provider took action to address the concerns we had about the safety of the windows at the service, ensured that all hazardous chemicals were stored securely and safely and addressed concerns we raised about unlocked doors with staff.

People told us staff responded quickly when they needed care and assistance. One person told us, “There’s somebody here 24/7 and if you want to call night or day they come to you.” People’s relatives felt there were enough staff to care for people. Comments included, “There are always a lot of staff about, they always have time for her. They are always very kind and cheerful. I go in mornings including weekends and the staff never seem rushed” and “There are enough staff to meet her needs, they are always chatting with her about her photos on the wall. She is never rushed; I have never witnessed anyone being rushed.” However, one relative did comment, “I am not sure they have enough staff. Sometimes the call bell is running for a very long time.”

Whilst most staff we spoke with told us there were enough staff to meet people’s needs, some staff raised concerns about the quality of the induction and training new staff received. Some staff felt new staff had not received adequate training and experienced staff were having to provide on-the-job training, which was impacting staff delivering timely care. Staff told us whilst they had access to face-to-face and online training, recently training scheduled was being cancelled. Comments included, “The training has been good generally, but recently without a deputy it has been hit and miss and things are cancelled” and “I have not done any online training and I am not sure if I have done any training this year. [Registered manager] has oversight but most of the training gets cancelled.” Staff gave mixed feedback about the support they received in the form of supervisions and appraisals. One staff member told us, “No, no regular supervision and no-one really oversees it at all or checks in with me. They might look at what we are doing but I am not aware of that.” Another staff member said, “Yes, I do have regular supervision and I usually have mine with [registered manager’s name]. Not sure how often it is just random, and I cannot remember the last time I had one.” We discussed induction, training and support with the registered manager who told us there was an induction programme in place that included training and shadow shifts. The registered manager told us they support staff with supervisions on a regular basis but did say that because of recent management staffing issues, supervisions had been difficult to keep up with. The registered manager told us staffing levels were kept under review and adapted to people’s changing needs.

During our site visit we observed people being supported by enough staff. Staff spent time talking with people and providing them with assistance when needed.

The registered manager told us staff received online and face-to-face training with 2 yearly updates for all training courses. However, the providers staff training matrix did not demonstrate that staff were receiving training every 2 years in subjects that would be considered mandatory in health and social care settings, such as, safe moving and handling, health and safety, fire training, MCA and DoLs and safeguarding adults training. For example, the training matrix showed that 9 staff had not received training on fire safety and another 9 staff, including the registered manager and provider, had not received a fire safety training update since 2021. Staff were not always supported by regular supervisions and appraisal according to the providers policy. For example, the provider’s policy stated that each staff member would undergo a formal review of job performance yearly and formal supervision reviews at 3 monthly intervals. However, records showed that no staff received an appraisal since 2022. Supervision records show that only 2 staff had received a formal supervision in 2024. Failing to ensure staff were supported with regular training, supervision and appraisal to enable them to carry out their duties well, is a breach of regulations. People were cared for by staff who had been safely recruited. Appropriate checks had been made to ensure new staff were suitable and safe to work with people living in the service, including police checks and employment references. An induction programme was in place that included staff training and shadow shifts.

People and their relatives told us the service was clean and staff always wore appropriate personal protective equipment (PPE) when supporting them. Comments included, ““My room is immaculate. Everything is tidy and clean. If you drop something on the floor, they don’t leave things lying around”, “They clean my room every morning, very conscientiously. Clean the floor, wipe door handles and work tops” and “They always put on a clean apron, they have a pack of gloves, fresh ones out of the box, wash their hands then put gloves on.”

Domestic staff described what they did to keep the service clean and tidy and what processes they followed. They told us they had access to the appropriate cleaning products they need to do their job. The housekeeper told us they completed cleaning checks and audits, but these were not reviewed by the registered manager. Staff confirmed they always used PPE when supporting people and had sufficient stocks of PPE available to them.

Whilst we observed the service was clean, we did observe unpleasant odours in 2 areas near people’s bedrooms and a shower room when we toured the building. We also noted that some areas were cluttered with equipment which would make keeping these areas clean and free from infection challenging. PPE was available for staff to use, and handwashing guidance was displayed around the building. We observed staff using PPE to support people safely.

Systems and processes in place to ensure people, visitors and those employed within the service were fully protected against infection control risks were not robust and there was a lack of oversight by the registered manager. The registered manager told us cleaning audits were completed by the housekeeper. However, the housekeeper was not able to show us any formal written audits as they only completed visual checks. Cleaning charts were in place, but these had not always been completed fully. For example, the deep cleaning chart for May 2024 shows 7 areas of the service were not deep cleaned. There was no oversight of the housekeepers’ audits and checks by the registered manager. There was no infection control audit in place as part of the providers governance and oversight. Whilst we found no impact, this meant that any areas of risk or staff practice that could be improved to mitigate potential risk was not being identified. We recommend the provider reviews governance systems and processes in place to manage the risk of infection.

Most people told us they received their medicines when they needed them. One person said, “They give it to me when I should have it. I have had it on time, always.” However, one person told us they did not always have their medicines on time and another person said staff did not always watch them take their medicines. We observed senior staff speaking kindly and taking time with people to make sure medicines were given safely. People were asked if ‘when required’ medicines were needed.

Staff told us they felt medicines systems worked well, and they could come forward and report any problems. They told us they had initial training and competency checks to make sure they could give medicines in a safe way. However, records showed that a few members of staff had not received updated training or an annual renewal of their competency checks.

Records showed people generally received their medicines as prescribed for them. However, improvements were needed to some areas of medicines processes. For example, medicated creams and in-use thickening powders were kept in people’s rooms. There were no risk assessments in place to check this was safe for people and care staff had not had specific training to apply these medicated creams. Medicated creams and applications were not always dated once opened. This meant that staff may be applying creams and applications that were not effective or less effective as they were out of date. Some people’s records lacked details and risk assessments for medicines, such as, for flammable external preparations, blood thinning medicines, and oxygen were not always in place. Person centred details for some ‘when required’ medicines to guide staff when these might be needed, were lacking. Allergies were recorded in care plans and some, but not all, were also recorded on people’s medicines records. We found one person where these did not match between the 2 systems. Audits were carried out and had identified some, but not all areas requiring improvements. These concerns demonstrated a breach of regulations in relation to safe care and treatment. Some actions were taken to start to address these issues during the assessment.