Pinewood Residential Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified one breach of the legal regulations. The provider failed to have effective systems in place to assess, monitor and improve the quality and safety of the service. Systems to assess and monitor medicines, risk management, infection prevention and control, application of the Mental Capacity Act 2005, staff training and environment safety had not identified or effectively addressed the concerns found during the assessment. Staff were supported to raise concerns, were positive about the registered manager and told us the registered manager and provider were approachable. However, some staff felt the current management arrangements were not ensuring the service was well led. Feedback from health professionals visiting the service was positive about staff and the registered manager and they said people had access to healthcare support when required.

This service scored 61 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager was also the registered manager of a sister service and split their time between the 2 services. The service did not have a deputy manager in post and management of the service when the registered manager was working at the other service, fell to the senior care staff on duty. Some staff commented they felt the current management arrangements were not ensuring the service was well led. For example, staff told us there was a lack of oversight at the service, and they felt under pressure when the registered manager was not available at the service. However, we received positive feedback from staff about the registered manager. Comments included, “I think [registered manager’s name] is generally a great manager and when she is in, she is easy to approach and she does get things done” and “Yes, the managers are doing well, and I am happy. I can go straight to her or message her and she is really supportive.” Whilst the registered manager was able to explain how to lead the service and deliver care, there were gaps in their knowledge and they had not identified the concerns we found in relation to the management of risk, environmental risks, medicines, staff training, the processes in relation to the MCA and DoLS and governance and oversight of the service.

The provider failed to ensure the registered manager received support to lead the service effectively which resulted in the issues and breaches of regulation we found. There were clear lines of responsibility at the service and staff understood their roles and who to go to for support. The registered manager and provider recognised their responsibilities under the duty of candour requirements and followed the service’ policies. The service had notified CQC in full about any significant events at the service. We use this information to monitor the service and ensure they respond appropriately to keep people safe.

Staff felt the manager was approachable and they could raise any issues or worries they may have with them. Staff told us they had staff meetings and most thought these were useful, and they could raise any concerns they had. The registered manager told us they had an ‘open door’ policy in place where staff knew they could drop in to the office at any time to discuss issues or raise concerns.

There was a transparent culture within the service. There was a whistleblowing policy in place that was accessible to staff to support them to report any concerns. Staff were supported with regular staff meetings where they were able to raise any concerns they might have.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they wanted to make improvements at the service and they had been working with the staff team to implement changes and lessons learned highlighted during a recent assessment of the registered manager’s other service. However, improvements had not yet been embedded, and we also found concerns which the management team were not aware of and had not identified prior to this inspection. Whilst staff told us the registered manager was a good manager, staff also felt recent senior management pressures resulting in a lack of oversight was having an impact on the service.

The provider's governance systems and processes were either not in place or did not effectively monitor the safety and quality of the service to promote good outcomes for people and keep them safe. We identified significant concerns with the provider's oversight of risks to people’s health and safety associated with their environment. For example, there was no environmental health and safety audit in place. People, staff and visitors were put at risk as fire safety checks, such as weekly fire tests and fire drills had not taken place. There was a lack of oversight of care planning and risk assessment documentation. For example, governance processes had failed to identify gaps in repositioning monitoring records, that care records were inconsistent and care record reviews were not being completed regularly. We identified a number of concerns with the management of medicines. Monthly medicines audits were completed and identified some areas for improvement. However, not all concerns we identified had been identified and/or actions put in place to address the issues. Although the provider had policies and procedures, these were not always being followed by staff. For example, staff did not consistently apply the policy in relation to MCA and DoLS. The failure to follow these policies risked compromising people's rights. The provider's governance systems and processes had not ensured that staff had received the support, skills and ongoing training to fulfil their roles effectively and safely. The provider’s training matrix showed that not all staff had received mandatory training and updates. Records showed that staff were not always being supported with supervisions and appraisal of their performance according to the providers policy. Systems and processes were not in place or not effective to monitor the quality of people's support and the provider was unable to make or sustain improvements at the service. This was a breach of regulations.

People and relatives told us healthcare professionals were contacted by the service, were involved in their care and visited regularly. People were encouraged to maintain relationships; visitors were welcome at the service.

Staff understood when people needed input from healthcare professionals and had appropriately arranged for people to be seen when required.

We received positive feedback from health professionals involved with the service. One health professional told us, “The registered manager always seems to know residents well and has up to date feedback about issues we have been addressing. They respond quickly when I have questions or need information. I am always struck by the friendliness and kindness of staff; this is really much more apparent than almost any other home I have visited.”

The registered manager and staff had developed good relationships with their local GP, district nurses and health professionals. Guidance from health professionals was included in people’s care plans for staff to follow.

We received mixed feedback from staff about how well they were supported to learn and develop. Some staff told us they had not received regular supervisions to discuss their performance and identify areas for further development and some staff told us they did not receive regular training. One staff member commented about their supervisions, “Not sure how often it is, just random and I cannot remember the last time I had one.”

The provider failed to effectively implement processes to drive improvement at the service. We identified areas where quality and safety had deteriorated to the extent where regulations were now being breached. The audits in place at the service did not identify the issues we found at this assessment. There was a process in place to record accidents and incidents at the service. The registered manager told us they would review accidents and incidents and take appropriate actions and look for trends and themes and learning from this would be fed back to staff.