We carried out an unannounced comprehensive inspection on 14 and 15 January 2019.

Pinewood Nursing Home is a care home with nursing for up to 30 people. On the day of our inspection there were 27 people living at the service. It specialises in care for older people who are living with dementia or have a physical disability.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Some of the people who lived in the home had limited communication therefore we spent time observing people.

At the last inspection, on the 27 June 2018 the service was rated Good overall. However, it has now been rated now Requires Improvement in Safe and Well Led. This was due to medicines not always being managed safely and the monitoring of medicines not being enough to reduce errors.

People’s medicines were not always managed safely or properly. People did not always receive their medicines as they should, including pain relief medicines. Some medicines were given and not signed for while others were not given but signed for.

We had received a concern in June 2018 in relation to medicines management. As a result, we asked the registered manager to send us the outcomes of their monthly medicines audits. These showed that the medicines management had not consistently improved in the service. On the day of our inspection we found six errors had already occurred in the last 12 days (3rd January to 14th January 2019). Action taken when audits had highlighted errors had not been robust enough to sustain good practice.

People lived in a service which had been designed and adapted to meet their needs. The provider monitored the service to help ensure its ongoing quality and safety. The provider’s governance framework, helped monitor the management and leadership of the service. The provider had monitoring systems which enabled them to identify good practices and areas of improvement.

However, though audits were carried out, medicines audits showed a high number of medicine errors including people not receiving their medicines as prescribed. Actions they had taken to improve practice had not been successful and medicines errors were found to have continued.

The registered provider took further action during the inspection. This included again writing to all staff to arrange additional in-depth medicines training and a letter outlining the issues we found.

Staff had completed safeguarding training and updates were provided. Staff had a good knowledge of what constituted abuse and how to report any concerns. Staff understood what action they would take to protect people against harm and were confident any incidents or allegations would be fully investigated. Staff confirmed they’d have no hesitation reporting any issues to the registered manager or provider.

People were protected by safe recruitment procedures. This helped to ensure staff employed were suitable to work with vulnerable people. Staff confirmed there were sufficient staff to meet people’s needs. Staff had completed appropriate training and had the right skills and knowledge to meet people’s needs. Staff also completed an induction programme when they started and their competency was assessed. Staff were provided training appropriate to the people they cared for, for example dementia care. Staff also completed formal care qualifications which included equality and diversity training.

People’s risks were assessed, monitored and managed

Pinewood Nursing Home provides care and support to up to 30 people, which includes older people, people living with a physical disability, sensory impairment and some people living with dementia. Accommodation is provided over two floors and the home is set in its own grounds and is situated in the rural village of Chidham, West Sussex. At the time of inspection, there were 28 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe with staff. Relatives had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of potential harm.

Potential risks to people had been identified and assessed appropriately. There were sufficient numbers of staff to support people and safe recruitment practices were followed. Medicines were managed safely.

Staff had received all essential training and there were opportunities for them to study for additional qualifications. Staff felt supported by the management, through supervision and appraisal. Staff monitored people’s health and took prompt action to address any concerns. People had access to healthcare professionals and appropriate referrals were made for guidance or additional support.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found the provider to be meeting the requirements of DoLS. We found the registered manager understood when an application should be made and how to submit one The registered manager and staff were guided by the principles of the Mental Capacity Act 2005 (MCA) regarding best interests decisions should anyone be deemed to lack capacity.

People were supported to have sufficient to eat and drink and to maintain a healthy diet. People’s rooms were decorated in line with their personal preferences.

Staff knew people well and positive, caring relationships had been developed. People were encouraged to express their views and were involved in decisions about their care as much as they were able. Their privacy and dignity were respected and promoted. Staff understood how to care for people in a sensitive way.

Care plans provided information about people in a person-centred way. People’s preferences and likes and dislikes were documented so that staff knew how people wished to be supported. Complaints were dealt with in line with the provider’s policy.

The registered manager was active in monitoring the care that people received and there were systems in place to monitor and audit the service. People, their relatives and staff felt able to raise issues or concerns with the manager, and were confident they would be listened to.

People could express their views and discuss any issues with the provider, registered manager or staff. The culture of the service was homely and family-orientated.

One inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. The home could accommodate 30 people and, when we visited, there were 28 people living in the home with one person in hospital for a short stay and one vacancy.

We spoke briefly with all the people living in the home and we spoke with five at greater length. We looked in detail at five care plans. We also spoke with five relatives who were visiting the home during our inspection.

We spoke with the registered manager and nine other members of staff including the cook, the quality assurance supervisor, nursing and care staff.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found that people's needs were assessed and their care and treatment was delivered in accordance with the care plan. There were assessments for risks such as manual handling, eating and the use of mobility aids.

Some of the people living in the home had complex needs and so the provider involved other healthcare specialists, such as, the dietician and tissue viability nurse, to ensure the provision of appropriate care and treatment.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We found that staff had received appropriate training to meet the needs of the people living at the home. This included core training in areas such as manual handling, first aid and fire safety. In addition, there was additional training in areas such as dementia and end of life care. We found that there was a good understanding of the mental capacity act and best interest decision making.

Staff were keen to use the most effective practices to treat pressure sores and to prevent falls, for example. We also found care staff sought advice, where appropriate, from the qualified nurses. The nurses provided a high standard of nursing care and we observed an effective handover meeting. A relative we spoke with said, ““The care in this home is excellent. The nurses are very experienced and capable”.

We spoke with the quality assurance supervisor about the on-going work to record and monitor falls within the home. This work had involved the staff working with the local authority ‘falls prevention team’ and had been productive in identifying patterns and may result, over time, in a reduction in the number of falls.

Is the service caring?

One person we spoke with said, “They look after me very well. I am comfortable and happy and I have everything I need.”

We saw that the staff were kind and sensitive and took time, so that people were able to do things at their own pace. We observed high levels of respect and people were treated with consideration and dignity. They were encouraged to make choices and to exercise autonomy and independence where possible. People’s rooms were furnished with personal items and staff knocked and waited to be invited in.

One member of staff said, “I love it here. There is a nice, warm and friendly atmosphere and we work well together.”

Is the service responsive?

People’s needs were assessed before they moved into the home and detailed care plans and risk assessments were maintained and reviewed regularly. We saw that the staff monitored weight, nutrition and hydration and maintained body charts for any sores or skin damage. Staff were diligent in assessment and monitoring and responsive to people's needs.

Call bells were answered promptly and staff were responsive to any changes in the health and wellbeing of people living in the home. If there were any concerns, care staff were quick to escalate issues to the qualified nurses and they would refer on to specialist healthcare professionals as appropriate.

The cook was a fully engaged member of the team and was responsive to different requests for meals and to any issues, such as portion size, raised by people living in the home or their relatives. The people we spoke with and their relatives were positive about the service and the food. The menus were well balanced and the cook was happy to respond to special requests for meals and to cater for special diets as required.

The activities coordinator was not present during our inspection, but people had access to a wide variety of activities within the home and, those who were able could take trips out.

Is the service well-led?

The home was well managed with a qualified team of professional care and nursing staff.

The provider collected feedback from the people living in the home and their relatives through regular meetings and surveys. The manager and staff acted on that feedback to improve the service.

The provider was using a structured framework to maintain high standards in the hone, for managing end of life care and for working with other healthcare partners.

Feedback from the relatives we spoke with was extremely positive and the people living in the home were happy with the care they received.

We spoke with three people living at the home. All were satisfied with the care and support they received and were happy living there. One person told us, "I love it here. It was difficult to adjust at first but it's my home now". Another said, "The nurses are wonderful and so caring too". A visitor we spoke with told us, "It's a very warm and caring atmosphere here. You can feel it when you walk in". The home also employed an activities co-ordinator; the people we spoke with praised the number and range of social activities on offer.

We spoke with the home manager, the deputy manager and five staff members. They all told us that they enjoyed working at Pinewood and felt valued as team members. One staff member said, "It really is a home from home here. I like coming to work". Another told us, "I've worked in places where there isn't the time to provide good care. It's very different here".

People told us what it was like to live at this home and described how they were treated by the staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by a practising professional and an Expert by Experience (people who have experience of using services and who can provide that perspective).

We used the Short Observational Framework for Inspection (SOFI) tool during this visit in the dining area during lunchtime. SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

Thirty people were resident in the home at the time of our visit. We spoke to six people individually who used the service and a visiting relative.

They told us people's care was provided by care workers who understood their or their relative’s care needs and that their privacy and dignity were respected. One person told us, “Our privacy is respected.”

People told us they felt they were well cared for by staff and that the staff were very caring and responsive to their care needs. Comments received were, “The standard of care here is very good,” “the staff brings their love into this place” and “I can’t find fault with any of them.”

People were able to express their views and were involved in making decisions about their care and treatment.

Five people who use the service told us that there was plenty of food and drink available, and the quality and choice of food provided in the home was satisfactory. Comments received included, “There is a good choice of food,” “the food is very good, I have a restricted diet and they are very helpful with this.”

People knew who to talk to if they had any concerns and they told us it was an environment where their concerns would be listened to and addressed. One person commented, “This really is a nice place,” and “the home owners are charming people.” Another person commented, “staff really look after my relative.”

Everyone said that they were treated with respect and that their views were listened to and acted upon. They also told us that they felt safe living at the home.

All people who we were able to have a conversation with said they were happy with the care they received.

Some people expressed the view that at times the home was short staffed.

Everyone said they were happy with the staff and that they treated them with kindness.