Pine Lodge

Date of assessment: 10 August to 28 August 2026.
Pine Lodge is a 3-bed respite service providing personal care and support to people with a range of complex needs, including learning disabilities, autism, epilepsy, communication needs, and physical health conditions. The inspection was prompted by a review of the information we held about this service, including concerns raised regarding poor governance within the organisation.
The service provides important respite opportunities for Service Users and their families. At the time of the inspection, 2 Service Users were returning home after a respite stay, and 1 Service User was coming in for 5 days stay. We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports the Care Quality Commission (CQC) to make assessments and judgements about services providing support to people with a learning disability and/or autistic people; this guidance was considered as part of the assessment.
Service Users and relatives spoke positively about the kindness, commitment and dedication of frontline staff. We observed warm and respectful interactions, and many relatives told us regular staff knew people well, understood their preferences and helped make their stays enjoyable and meaningful. Families described the service as an important source of support and valued the relationships people had developed with staff.
However, significant concerns were identified regarding the quality, safety and governance of the service. Systems intended to assess, monitor and improve care were not operating effectively. Information demonstrating potential risks was available through incidents, daily notes, medication records, audits and family feedback, yet governance systems did not consistently identify emerging concerns, recognise patterns of risk or ensure learning was embedded into practice.
We identified serious concerns relating to medicines management, including medication errors, inaccurate allergy records and failures to appropriately escalate medicines-related risks. Safeguarding systems were not consistently effective, and recurring incidents involving unexplained injuries and self-injurious behaviour were not always recognised as emerging concerns requiring further review. We also found examples where deterioration in people's health and wellbeing was not consistently escalated or reviewed in a timely way.
We identified 4 breaches of regulation relating to the quality and safety of care provided. Areas requiring improvement included the application of the Mental Capacity Act 2005, medicines management, risk management, person-centred care, and governance. As a result of the concerns identified, the Care Quality Commission took enforcement action against the provider.
Following the inspection, senior leaders took significant action, including introducing direct leadership oversight, commissioning external support, temporarily suspending the service and implementing improvement plans. Whilst these actions demonstrated commitment to improvement, they were largely implemented in response to concerns identified through inspection rather than through the provider's own governance systems.
While people and relatives often described compassionate and committed frontline staff, weaknesses in governance, medicines management, safeguarding oversight and risk management meant the provider could not demonstrate care was consistently safe, effective or legally compliant. Whilst people were not routinely experiencing immediate harm, the concerns identified significantly increased the risk of unsafe care, inconsistent decision-making and avoidable harm in the future.