Pinhoe View

Independent Healthcare Org · South West

Overall Rating
Requires Improvement Last inspected 30 November 2022
Domain Ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Requires Improvement
Responsive
Requires Improvement
Well-led
Requires Improvement

View Full CQC Report

9 must-do actions
6 should-do actions

Must-Do Actions (9)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Caring
The provider must ensure that patient's rights to privacy and dignity are protected. Staff must acknowledge patients' presence and ensure they are always correctly addressed and not referred to as initials or room numbers.
Regulation 10 HSCA (RA) Regulations 2014 Dignity and respect
Staff interaction was not always respectful towards patients. At times staff ignored patients when they sought their attention and support. Staff referred to patients by room numbers or initials during their discussion.
Must Do
Caring
The provider must ensure privacy frosting does not obscure patients view of the outdoors. This meant that did not have a direct link to the outside community.
Regulation 10 HSCA (RA) Regulations 2014 Dignity and respect
Privacy frosting obscured patients' view of the outdoors, meaning they did not have a direct link to the outside community.
Must Do
Effective
The provider must ensure that care plans and risk assessments are developed in a way that ensures patients preferences are detailed. Care Plans must meet Accessible Information Standard (AIS) for patients with sensory loss.
Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
Care plans lacked patients' preferences on how they wanted their needs to be met. Care plans and risk assessments were not always developed for all areas of need and used standard statements. Care plans did not meet Accessible Information Standard (AIS) for patients with sensory loss.
Must Do
Well-led
The provider must ensure that all staff have appropriate access to electronic notes.
Regulation 17 HSCA (RA) Regulations 2014 Good governance
Staff were not always provided with access to electronic care notes, meaning verbal and written handovers were the main form of sharing key information with staff.
Must Do
Safe
The provider must ensure that the ratio of female patient to male staff is appropriate to meet the needs of patients.
Regulation 18 HSCA (RA) Regulations 2014 Staffing
The ratio of male staff was high in comparison to the female patient ratio, leading to complaints about male staff on night shifts.
Must Do
Safe
The provider must ensure the premises are suitable for the purpose being used which must include window closures.
Regulation 15 HSCA (RA) Regulations 2014 Premises and equipment
The premises were not suitable for purpose as window closures were not working, meaning patients could not close windows and communal areas were cold.
Must Do
Safe
The provider must ensure that all staff have completed appropriate mandatory training.
Regulation 18 HSCA (RA) Regulations 2014 Staffing
Not all staff had completed and kept up to date with their mandatory training, with overall compliance below the hospital target of 90%.
Must Do
Well-led
The provider must ensure that their governance systems and audit programmes are effective in identifying and mitigating risks.
Regulation 17 HSCA (RA) Regulations 2014 Good governance
Governance processes and audit programmes were not always effective in identifying and mitigating risks, and in developing plans to address identified issues.
Must Do
Well-led
The provider must ensure they complete the actions contained in their improvement plans.
Regulation 17 HSCA (RA) Regulations 2014 Good governance
The provider's governance systems were not effective in developing plans to address identified risks and improvements needed, indicating a failure to complete actions in improvement plans.

Should-Do Actions (6)

Recommended improvements to enhance service quality.

Should Do
Effective
The provider should ensure all staff receive an appropriate induction to the hospital.
Should Do
Effective
The provider should ensure all staff have knowledge and understanding of the rights of informal patients and those detained under the Mental Health Act (1983)
Should Do
Responsive
The provider should ensure discharge plans are personalised and regularly reviewed.
Should Do
Responsive
The provider should ensure all patients have allocated times to undertake laundry.
Should Do
Well-led
The provider should ensure all staff receive regular supervision sessions.
Should Do
Responsive
The provider should ensure all patients are able to access leave.
Location Details
CQC ID: 1-10650031112
Local Authority: Devon
Region: South West
Inspection Report
Type: Comprehensive inspection
Date: 30 November 2022
Rating: Requires Improvement
Actions: 9 must-do , 6 should-do
AI-extracted 17 Feb 2026