Portelet Manor Rest 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

We found improvements had been made since our previous inspection and at this assessment we found people were safe. The service was no longer in breach of regulation, in relation to risk assessment and risk management. There were sufficient numbers of suitably qualified staff to meet people’s needs. Robust and safe recruitment practices were in place. Safeguarding processes were followed, and staff were aware of reporting systems. People were supported to access healthcare professionals when required. However, some recording shortfalls remained.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a complaints policy in place. The complaints procedure was clearly displayed in the home. Relatives felt they were able to speak with the registered manager about issues concerning the care of their loved ones. The service had not received any formal complaints since our previous inspection.

Staff were supported by the registered manager. Staff told us, ''I feel supported.'' Staff told us they were encouraged and supported to raise concerns, they felt confident they would be treated with compassion and understanding.

Incidents and accidents were not always reported to the registered manager in line with the provider's policy and therefore not updated on the electronic recording system used by the service. This meant the provider could not be assured they had all the information needed to learn from accidents or incidents and prevent re occurrence. There was no system in place to share any learning from adverse events.

Relatives told us the service had an effective working relationship with external agencies. One relative told us, ''The home is very good, well connected with the surgery, the staff here get (my loved one’s) antibiotics and make sure (they are) seen by the regular Doctor that visits if (my loved one) needs it, they call the Doctor in between the round visits too when needed.''

Staff told us they worked closely with services, such as GP practices and social services. For example staff attended a meeting with one person's GP, social worker and relative, to discuss the person's current needs and any changes required to the agreed support. Staff felt confident accessing people’s care plans.

People were supported by a wide range of professionals. Comments from professionals included, ''We had noticed an improvement in the home.'' Another external professional told us they had noticed improvements in medication storage and staff induction.

Fire policy and procedure were clear and up to date. The service's fire evacuation grab bag had up to date information about how people should be supported in an event of an emergency and was regularly reviewed. The service worked with the local fire service to make necessary changes to the building. This included fitting new fire doors for all people's rooms.

We saw kind and respectful interactions between people and staff. One relative told us, ''I visit unannounced, they don't know I am coming and (my loved one) is in here (lounge) clean and comfortable the carers are good to (my loved one) you see.'' People did not raise any concerns about their safety during our assessment.

Staff understood safeguarding procedures within the home. Staff told us if they report any concerns to the registered manager, they were confident action would be taken. Staff were also aware they could report any concerns externally to the local authority or CQC.

People were comfortable in the presence of staff. People received care and support in line with their assessed needs and looked clean and well-dressed. We observed an inclusive culture and staff interactions with people were respectful. It was evident that staff knew people well.

Potential safeguarding concerns were reported to the local authority safeguarding team. However, the provider did not have robust oversight of safeguarding in the service. This meant there was a risk they may not identify any themes and patterns.

Relatives we spoke with were positive about care provision. Comments included, ''I've no concerns at all. (My loved one) has stabilised, (they) truly has and we've had a meeting to reduce extra support."

People were supported by competent staff who were happy in their work. Staff told us they had time to read people’s care plans and risk assessments and knew how to support people safely.

We observed people being supported by sufficient numbers of suitably qualified staff. Staff supported people safely and with kindness.

The provider had failed to implement a system to ensure risk assessments were routinely reviewed so information remained relevant and up-to-date. In response to our feedback, the registered manager acted immediately and implemented risk assessments where required.

Improvements to the environment had been made and people confirmed this, ''They've had a lot of work done…it's quietening down now but we've seen a change.'' Relatives told us the home is, ''Not the poshest care home out there, but staff are really lovely and have time for everybody.''

The registered manager told us the staff met daily to discuss maintenance and health and safety concerns. However, we found periods of weeks where meetings had not been completed. We discussed our findings with the registered manager who following the assessment shared with us a new service improvement plan which listed a number of improvements planned for 2024.

During the onsite assessment we found 1 fire extinguisher which had not been tested since October 2022, 1 fire door with the fire seal sticking out of the side and 1 mattress pump which had not been PAT tested on time. We also found 1 of the boiler rooms had no lock on the door. We informed the registered manager of our findings and they took immediate and appropriate action to ensure these shortfalls were corrected.

There was no formal action plan following a fire drill and evacuation simulation report given to the home at the beginning of April 2024. This report identified several areas for concern and recommended actions to be taken. This was brought to the attention of the registered manager who took appropriate action to address the shortfalls identified.

Relatives told us that staff had a caring approach to people living in the home. One relative told us they were grateful to the registered manager for their help and advice. People did not raise any concerns about the number of staff working in the home.

Staff told us they felt well-supported and valued. Staff confirmed they received sufficient training to carry out their roles effectively and felt it helped them to, ''Do things better and offer the best care for our residents.''

We observed people being supported by sufficient numbers of suitably qualified staff. One person required 1:1 support for a large number of hours each day, we observed the correct numbers of staff were available to provide this.

The provider operated robust recruitment processes. All applicants were required to complete Disclosure and Barring Service (DBS) and reference checks prior to commencing employment in the service. DBS checks are important because they alert employers to individuals who are barred from working with people who receive a regulated activity.

Relatives we spoke with did not raise concerns about the cleanliness of the service. People appeared happy and comfortable in their surroundings.

The registered manager told us they had recently implemented a suite of new policies and procedures including Infection Control Policy and Procedure. These were stored electronically and accessible to staff. All the policies looked at during the assessment were up to date.

The home was clean on both days of our assessment. Personal Protective Equipment (PPE) was available for staff to use when needed. We observed staff cleaning throughout both days of onsite assessment. At the time of the assessment the home held a food hygiene rating of 5 which meant hygiene standards are very good and fully comply with the law.

Appropriate arrangements were in place to control the risk of infection. Staff had been trained in infection control techniques and had access to PPE. The provider's Infection Control Policy and Procedure reflected current practice guidelines.

People, their relatives and external healthcare professionals did not raise any medicines related concerns during our assessment.

Staff members told us they felt confident accessing people's care plans. One staff member we spoke with was able to confidently explain the correct process for reporting any concerns they may have regarding medicines in the home.

The provider failed to consistently check and audit all aspects of medicines management. We found one occasion when the provider had failed to undertake a stock check of controlled drugs in line with their policy. The lack of medicines oversight meant the provider had failed to identify this shortfall. In response to our feedback, the registered manager introduced new systems and checks to help to prevent a recurrence.