Portelet Manor Rest Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service continues to be in breach of regulation relating to good governance. The provider failed to ensure systems to assess, monitor and improve the quality and safety of the service were in place and effective. We identified several concerns with the oversight of key areas of people's care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt part of the shared direction and culture and told us they liked working in the home. Staff and leaders were committed to the people living at the service.

There was a positive and person-centred culture in the service. Staff had access to people’s care plans and spoke knowledgably about the people they supported. Staff were happy in their roles. People were supported to access activities outside of the home.

Staff told us they were encouraged to provide feedback and make suggestions to the senior leadership team to encourage improvement within the service. Staff we spoke with were positive about the registered manager. Comments from staff included, '‘(The registered manager is) approachable and supportive. She is a nice person.'' and ''The registered manager looks out for the staff.''

The service had a friendly and welcoming atmosphere. Systems and processes were in place to support positive relationships between managers and staff. The registered manager had an open-door approach and staff felt supported in their roles.

Staff told us they felt confident in speaking up if they had any concerns about the care being provided or any other issues around the home. Staff confirmed they knew how to whistle blow and to report concerns to external organisations if necessary.

The communication within the home had been improved by the registered manager who organised staff meetings, with the last one held in March 2024. During the meeting staff were encouraged to share their views of the service. Staff discussed people's assessments and the importance of keeping up to date with people's changing needs. The provider had a whistle blowing policy which provided guidance on how concerns could be raised.

People were supported by competent staff who were happy in their work. Staff told us they felt supported in their roles. Staff told us the registered manager and the management team, '‘Do not discriminate'’.

The home was an inclusive workplace where staff were treated and supported as individuals. Staff told us they were able to ask for reasonable adjustments to be made to their working pattern for specific needs, for example to incorporate family commitments or to look after their loved ones.

Audits carried out had not always identified shortfalls found during the assessment. This meant quality performance had not always been assessed, potential risks to people were not always identified and lessons learned to drive improvements had not always been possible. The registered manager was responsive to us during the assessment, addressed shortfalls identified and created new systems when needed.

During the assessment we found that the provider had failed to ensure quality assurance and governance systems were operated consistently and effectively. For example, the provider failed to identify daily records did not always reflect that people had been repositioned in line with their assessed needs. We found no harm to people in relation to this recording shortfall. We reported our concerns about recording to the registered manager who responded by introducing improved repositioning charts during this assessment. Some people were monitored for weight loss and assessments were in place detailing how frequently those people should be weighed. Records we reviewed did not always include entries to confirm people had been weighed in line with their assessments. We found no harm to people in relation to this recording shortfall. Providers must ensure their ratings are displayed conspicuously and legibly at each location delivering a regulated activity. The provider’s ratings were not displayed during the first day of this assessment. In response to our feedback, the registered manager ensured the service’s rating was displayed on the premises in line with the regulation. We identified 4 statutory notifications had not been submitted in line with the regulations. Statutory notifications are important because they inform us of notifiable events and help u to monitor the services we regulate.

People were always acknowledged by staff when they spoke, and staff interacted with people who did not appear able to be able to communicate verbally. Staff knew people well. People were encouraged to maintain relationships, visitors were welcome to the home.

The registered manager told us they could access healthcare professionals when they were needed. We saw evidence of this in form of an email.

People were supported by a range of professionals. External health care professionals told us that they had noted improvements in the running of the home this year.

The records of interactions with external healthcare professionals were not always completed which meant that the information could not be easily found and there was no oversight. This meant communications regarding people’s health were not always effective.

The provider introduced staff and people surveys, however these were not analysed or used to drive improvement within the service.

We identified some gaps in people’s training, however the registered manager had introduced new face to face training and improved fire training sessions. There was a clear plan to complete all out of date training. The registered manager used an electronic communication system to send messages reminding staff about their training.