Archived: Pinewood Rest Home

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• 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

At this assessment we found shortfalls in the quality of care. We found breaches of the following regulations of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People did not always receive their medicines as prescribed or in line with manufacturers instructions. Care planning around people’s medicines did not always contain person specific instructions or information to reduce risks, putting people at increased risk of coming to harm. This was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Assessments and evacuation plans were not sufficiently robust to reduce risks related to fire safety. This was a continued breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as we identified a breach in this regulation during our last inspection in July 2022. After this assessment we made a referral to the local fire and rescue service regarding the shortfalls we found in relation to fire safety arrangements at the service. The provider failed to ensure they completed robust recruitment checks when employing new staff. This increased the risks that unsuitable staff may be employed to work with people. This was a continued breach of Regulation 19 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as we identified a breach in this regulation during our last inspection in July 2022. The provider had failed to ensure all staff had received sufficient training appropriate to their role and there were not always sufficient numbers of staff deployed. This was a breach of Regulation 18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had appropriate systems in place to assess people’s capacity to make decisions about their care. We identified some safeguarding incidents which the provider had not reported to the local authority as required.

This service scored 50 (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.

The provider had appropriate processes in place to ensure that when people lacked capacity, decisions were made in their best interests. They had submitted applications to appropriate authorities when people were assessed as needing applications to deprive them of their liberty under the appropriate statutory framework. We identified some incidents that the provider had not reported to local safeguarding teams that may have met the threshold for reporting. We advised the provider to contact the local safeguarding teams in respect of these incidents. There was limited evidence that the provider analysed safeguarding incidents to identify root causes or trends. This meant there were potential opportunities lost to reduce the risk of recurrence.

People told us they felt safe living at the service and that they were happy with the staff and care they received. Nobody we spoke to raised any concerns related to their safety or wellbeing. Relatives told us they had no concerns about people’s safety. Comments included, “The family visit at least every 2 days and there are no concerns as to the care for our loved one."

Staff had a good understanding of safeguarding processes and were able to identify signs of abuse and appropriate actions to take in response to help keep people safe. Staff knew people well and told us they could notice changes in people’s presentation or behaviour that would indicate there were concerns about their safety or wellbeing. Staff had received training in The Mental Capacity Act (2005) and understood the importance of minimising any restrictions to people.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff raised concerns that evacuation plans were not effective as some evacuation equipment was not suitable for use. The registered manager took action in response to feedback and sent CQC evidence that they had reduced risks around kitchen fires by cleaning cooker hoods, which were which we observed were ingrained with grease.

The fire risk assessment for the service had not been reviewed by a competent person since July 2022. This should be reviewed at least annually to help ensure fire safety arrangements reflected most current risks. Arrangements to ensure water temperatures were in safe range for people to use were not always robust. The provider’s records demonstrated the temperature of water from taps reached as high as 55 degrees, which posed a risk to people. Staff were provided with thermometers to take the temperature of bath water before use. However, not all the thermometers were accessible to staff or in good working order. Therefore, this was not a reliable process to ensure the safety of the water temperature.

People did not raise any concerns about the safety of the environment at the service. People told us they felt safe living at the home.

We observed a fire exit on the first floor that was secured using a bolt fitted at the top of the door. This posed a risk to people as it could be difficult to reach when trying to open the door in the event of an evacuation. Fire exits on the first floor were not always clean or free from debris. This could pose a hazard to people using this route during an evacuation. One bedroom had a cupboard containing electrical equipment. There were paint containers stored in this cupboard, which increased the risk of fire. The cupboard was not fitted with a fire-resistant door, which would have been an additional safety measure if a fire should ignite. We observed that staff were not signing into the building as they entered and left. This meant that there was no register of who was in the building, which would be needed to account for people’s safety in the event of an evacuation.

Staff were generally positive about their role. However, some staff felt they would benefit from increased frequency in supervision meetings, where their training and development needs could be discussed.

The provider did not have safe systems in place around the recruitment of staff. We reviewed a sample of staff recruitment files and found examples where there were gaps in employees work history and the provider had not always ensured that references were obtained from candidates’ previous employment in health and social care. These are requirements which help to ensure that suitable staff are employed to work with people. Systems to ensure staff received all training appropriate to their role were not effective. A significant number of staff had not received training in key areas such as, safeguarding and The Mental Capacity Act 2005. There was limited evidence that the provider assessed staff’s competence in key areas such as, moving and handling and medicines administration. This was not in line with the provider’s policy or best practice guidance. Staffing rotas reflected a shortfall of staff, which was below the ratio the registered manager stated the service needed to meet the needs of people. For example, there was no chef working on 21 out of 28 days from the staff rotas we reviewed. This meant that care staff were responsible for preparing food, taking them away from carrying out their caring duties.

We observed staffing levels and staff interactions with people across the 2 days of our assessment site visit. We found that staff were kind and attentive people throughout the day when supporting them with requests or during mealtimes.

People told us that staff were caring and hard working. However, there was mixed feedback about staffing levels, with some people telling us they were attended too quickly, whilst others told us the service was often short staffed. Comments included, “If I call them [staff] on my call bell they usually come quickly” and, “[Staffing levels] are a bit short. Staff tell me they are short, particularly in the mornings, but I know I have to be more patient [when waiting for assistance].” Relatives told us there were often shortages in staff, including recently where the service did not have a permanent chef. This meant that that care staff were reassigned from care duties to cover this role.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke with said they had their medicines when they needed them. Comments included, “They bring it [medicines] to me when I need it” and, “My antibiotics were given to me as soon as I needed them.” Relatives told us they had no concerns about medicines and that their loved ones received their medicines as prescribed.

People we spoke with said they had their medicines when they needed them. Comments included, “They bring it [medicines] to me when I need it” and, “My antibiotics were given to me as soon as I needed them.” Relatives told us they had no concerns about medicines and that their loved ones received their medicines as prescribed.

People did not always receive their medicines as prescribed or in line with manufacturers guidance. For example, one person was administered the incorrect dosage of one of their prescribed medicines for a period of 2 days. In another example, staff were administering inhalers to people directly from refrigerated storage. This was not in line with manufacturer’s instructions and potentially reduced the effectiveness of these medicines. Staff competency assessments for the management of controlled drugs were not regularly carried out. This was not in line with best practice guidance. Controlled drugs are medicines which are subject to strict legal protocols around their use and storage. Medicines care planning lacked detail around people’s specific requirements and risks related to medicines. This included information related to ‘when required’ medicines and reducing fire risks associated with the use of emollient creams.