Pinelodge Care Home

On this page

• 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

At our last inspection the provider had failed to take sufficient action to address the areas in the home that required refurbishment in a timely manner. This was a breach of regulation. Enough improvement had been made at this inspection with regards to the refurbishment of the service. However, whilst the provider had assurance checks and audits in place, these did not provide an accurate overview in relation to the safety and quality of the service for the registered manager. The provider remains in breach of regulation. Governance systems were not robust. We found inconsistencies within data and information provided, which had not been identified by the registered manager. Staff gave positive feedback about the management of the service and felt informed and listened to.

This service scored 54 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 systems of checks and audits completed at the service were not always consistent. The system in use was disjointed and the benefit of the audit, how the information was used and action was taken from the results was not always clear. It did not enable the registered manager to have effective oversight at the service. The registered manager was able to provide records with ease during the assessment, however we were not assured of the reliability of the data and information as we found multiple errors in the records and conflicting information. The registered manager felt that the implementation of the electronic care planning system would resolve the issues found. There was a clear staffing structure at the service, with each role understanding their position and responsibilities. Information was shared as needed with other agencies. This included statutory notifications as required by CQC.

Staff were positive about the management team and how the service ran. They told us they were kept informed of events and updates, felt supported and listened to. Staff also told us there were regular checks to ensure they were working in line with expectations and training. A staff member said, “They share the lessons learning from a complaint, accident or safeguarding. An example of this was about fall from heights. The lesson and the reminder for us, is to make sure to check / re-assess the service user who are at risk of falling out from bed and to follow the policies and procedures in place to prevent/ avoid this type accident in the future. They carry out spot checks to ensure best practice and asked us for our views and opinion in lined with our work.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.