Pinelodge Care 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

Audits and checks were completed with regards to safety, equipment, and risks. A monthly summary was compiled for each unit and shared with the registered manager by senior staff, however analysis for themes and trends and the actions taken in response was not evident. Anomalies in data and information did not give assurances that oversight of safety was robust. The registered manager stated they would take action to make improvements. Care plans and risk assessments were in place, however some of the records viewed would benefit from further information being included. We shared this feedback with the registered manager who felt the introduction of the electronic care planning system would address this, but confirmed they would complete a review of the documentation currently in place. People told us they felt safe living at the service and had no concerns for their health, safety or wellbeing. We observed staff working safely and using equipment to mitigate risks to people. The environment was clean and hazard free. Infection prevention and control measures were in place.

This service scored 59 (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.

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

People said they felt safe when being supported by staff. We spoke with people about the use of bedrails as, information shared with us prior to the assessment by partner agencies, indicated this was an area of concern. People told us they either wanted or felt they needed the bedrails. One person said, “I need them, had some falls, I’d be frightened without them.” Other people observed with bedrails were frail and their care needs indicated the need for the use of bedrails. People told us staff were responsive and came when they needed them. One person said, “I’m very happy, I can’t fault them (staff), they come really quick.”

Risk assessments were in place. Where appropriate mental capacity assessments had been completed and DoLS applications made. However, some records seen would have benefitted from more detail. The registered manager told us that the implementation of electronic care plans would resolve this as the system provided a more robust assessment process for each risk identified. Where people sustained minor injuries, we saw these were recorded and reported to the registered manager. However, whilst reported to the registered manager, an analysis of injuries was not completed to identify any potential themes and trends. The registered manager completed this process during the inspection process and advised this would be in place and routinely completed going forward. We reviewed processes in place to manage risks in an emergency. People had personal evacuation plans in place and these had been reviewed regularly. Staff told us they were aware of how to support people in the event of an emergency, such as fire, however staff training records indicated that 28 members of staff had not completed ‘fire safety’ training or a refresher course in the subject. We raised this with the registered manager who stated this could be explained as an administrative error on the record and they would complete a full review. We reviewed records of the 3 most recent fire drills completed. Each record showed that the drill had taken 1 hour and 35 minutes to complete, with the same remedial action required on each occasion. We raised this with the registered manager, and they stated they were unaware of this issue. They determined that the length of time documented was inaccurate and included training time as well as the drill. They confirmed they would ensure that records would be completed more clearly in the future.

Staff were aware of people’s risks and needs. One staff member said, “If a service user can’t use the call bell, a risk assessment is being done. We have a routine rounds to check everyone and a specific round to those in need of close monitoring.” We discussed the use of bedrails to mitigate risks to people with staff. Staff advised people had bedrails to help prevent them from falling. One staff member said, “(We use) bed rails to prevent falling and sustaining an injury from fall. It is not used to restrict or limit a user’s freedom to leave their bed, but to protect themselves from injury. In some case bed rails may increase the risk of falling because the user may climb up or the bed rails may break from an erratic movement. This is why a rigorous risk and behaviour assessment should be done before prescribing bed rails for the bed occupier. It should cater the occupiers best interest only.” One staff member did give us unclear information about using bedrails for a person with a view to calming them, when unsettled or showing signs of distress. We discussed this with the registered manager, and asked other staff members, to determine if this as an approved protocol. We were advised this was not and the registered manager confirmed they would take action to address this. We also discussed the use of bedrails with low beds and mattresses on the floor, which would not be a usual practice. The registered manager advised that normally a lowered bed and mattress on floor would be used instead of bedrails where people were at risk from climbing over bedrails but recently had received conflicting advice from external professionals about what was to be used. They confirmed they would seek to resolve the conflicts in the advice received and had a meeting arranged with partner agencies.

We observed staff working safely. Staff were completing checks on people in their rooms and staying in communal areas when people were present. We observed a person calling out from their bed, as they wanted to get up. We noted they had bedrails in place, their bed was lowered with a mattress on the floor and a sensor mat. We asked staff why they were not attending to the persons request and was advised they had returned from hospital and were resting. The person had previously sat in a reclining chair and had no history of falls from this position. We asked the person to be assessed swiftly to aid them to get out of bed and sit in their chair if it was safe to do so. We were advised this assessment was being completed.

People felt safe in the environment they lived in. One person said, “I feel absolutely safe.” Another person said, “I like my bedrails, stops me feeling like I’ll fall out. They’re (staff are) kind. Comfortable most of the time. Come when I need them, I’m not worried about anything.”

We observed no hazards in the environment, with clear signage and fire fighting equipment in place. We saw a communal corridor was being painted on the day of our visit. We saw that some walls and woodwork was chipped or marked but a rolling redecoration plan was in place to address this. Equipment was, in the main, being used appropriately.

At the time of our visit to the service, the registered manager advised there was a heating issue affecting an area of the service. Work to address this was planned and they explained what was in place to manage this until it was fixed. They said, “Risk assessment in place, on [name of unit] we are unable to have freestanding heaters due to risks of people touching them or tripping over them. We are layering clothes, regular hot drinks and observations of the temperature.” Staff felt they had access to appropriate equipment. Individual slings for use with hoisting equipment were in place however the registered manager explained there was an issue regarding labelling of slings and this was being resolved. One staff member said, “There is a risk assessment in place and all in working order. These will gradually be replaced.”

There were processes in place to ensure that the environment was safe. Equipment in place was checked, routinely serviced and tested as required. Equipment audits were completed by senior staff and shared with the registered manager. Whilst the registered manager verbally confirmed action was taken in response if any improvements were required, this was not recorded. We found some inconsistencies between some audits and checks completed, however the registered manager felt this was due to people moving rooms in the time period between checks.

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

Staff were able to tell us about good infection control practice. We asked staff about how they managed any outbreaks in the home. All were able to explain how this was done safely. A staff member said, “Everyone should be cautious to prevent and minimize the risk of outbreaks and infections in the workplace.” Another staff member said, “We have to restrict moving around the home and if we need to, we have to wear PPE.”

People had their own space which was cleaned daily. No concerns were shared with us in relation to infection prevention and control.

There was an infection prevention and control policy in place, which had recently been reviewed by the registered manager. There was clear guidance in place for staff including any actions that should be taken should an outbreak be suspected or confirmed. The registered manager completed a reflection following an outbreak to determine if any lessons could be learnt or improvements made for any future events. This was shared with the staff team. However, we reviewed the most recent reflection completed and found inconsistencies within the record and that the 'lessons learnt' identified were statements of good practice. This did not provide evidence of an in depth review or robust process.

The environment was clean and there were cleaning staff working on each unit. There were no malodours and there was clear signage on display about infection control. Personal protective equipment (PPE) was available, with donning and doffing areas in use as needed.

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