CQC report explained · a residential care home
What the CQC found at Portcullis House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection-control arrangements, including visits, testing, admissions and outbreak management. They were only somewhat assured about PPE use and premises hygiene because of a mask risk assessment issue and items in a communal bathroom.
- Effective?
- Good
- Not assessed in this targeted inspection.
- Caring?
- Good
- Not assessed in this targeted inspection.
- Responsive?
- Good
- Not assessed in this targeted inspection.
- Well-led?
- Good
- Not assessed in this targeted inspection.
What inspectors found, March 2021
Inspected but not rated; inspectors found good infection-control arrangements, with two PPE and communal bathroom issues addressed during the visit.
This was an announced, targeted inspection on 18 February 2021. It focused on infection prevention and control during the coronavirus pandemic, rather than the full quality of care.
Inspectors were assured about visitors, social distancing, admissions, testing, outbreak management and the infection-control policy. The home also supported visits through a divided conservatory and helped people keep in touch by telephone and video calls.
Inspectors were only somewhat assured about PPE use and the safety of premises and hygiene. A temporary worker was not wearing a mask in one area without a risk assessment, and personal toiletries and cloth hand towels were found in a communal bathroom. The manager said action would be taken, and action was taken about the bathroom.
The service was inspected but not rated. This means the report does not give a full overall rating or ratings for the other four questions.
Safer visiting arrangements
The home had a specially divided conservatory for visits, with separate access for visitors and cleaning time between visits.
“Visitors were able to enter directly from the carpark and therefore did not have to come through the service.” from the report
Keeping families in touch
Staff supported people to maintain contact with relatives and friends by telephone and video calls.
“Staff also supported people to keep in regular contact with friends and families through telephone and video calls.” from the report
Health monitoring
People had their temperatures checked twice a day, and staff looked for signs and symptoms of coronavirus.
“Each person had their temperature taken twice daily and staff were vigilant about looking for any signs or symptoms of Covid-19.” from the report
Professional advice
Weekly meetings with health and social care professionals helped the home get advice about concerns promptly.
“There were weekly multi-professional meetings held via social networking with a GP, a pharmacist, district nurse, physio and a social worker.” from the report
PPE risk assessment
needs fixingA temporary member of staff was not wearing a mask in one area. The report says this had not been risk assessed for possible risks to other staff.
“However, where a temporary member of staff was not wearing a mask in a particular area which people in the service did not enter, this had not been risk assessed in terms of risks to other staff.” from the report
Communal bathroom hygiene
needs fixingPersonal toiletries and cloth hand towels were present in a communal bathroom, creating a risk of infection spreading. The manager took action to address this.
“However, there were personal toiletries and cloth hand towels in a communal bathroom which posed a risk of cross infection.” from the report
- 01What action was taken after the temporary worker was found without a mask, and how do you now risk assess PPE use in all areas?
- 02What changes were made to the communal bathroom after personal toiletries and cloth hand towels were found there?
- 03How do you check that staff use PPE safely and effectively every day?
- 04How are visits currently arranged, and how is the visiting area cleaned between visits?
- 05How do weekly meetings with health and social care professionals help when someone develops a health concern?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not rate the other four questions or the service overall. This explanation was written from the published report of 10 March 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2019
Rated Good; inspectors found kind, person-centred care and improvements since the previous inspection.
This was an unannounced comprehensive inspection on 12 March 2019. Two inspectors and an expert by experience spoke with people living at the home, visitors, a healthcare professional and staff. They also checked care plans, training, medicines and recruitment records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were safe, treated with kindness and dignity, and supported by staff who understood their needs.
The report says the home had improved since the previous inspection, when it was rated Requires improvement. Care plans, activities, risk management and quality checks had improved. The home did not have a registered manager at the time, although an experienced relief manager was running it with support.
Kind and respectful care
People told inspectors that staff were kind, patient and respectful. Inspectors saw people being helped without being rushed, and their dignity and choices were respected.
“People told us staff were kind and patient and we saw this during the inspection.” from the report
Personalised care planning
Care plans had been reviewed and gave staff clear information about people's needs, wishes and routines. Families had also been invited to take part in reviews.
“Since the last inspection care plans had been reviewed and up dated to make sure they gave staff clear information about people's needs and wishes.” from the report
Improved safety checks
Risks were assessed and control measures were in place. A new checking system was used to make sure pressure-relieving equipment was correctly set.
“Since the last inspection the provider had implemented a new checking system to make sure equipment was correctly set to give maximum benefit to people.” from the report
Activities based on interests
The home asked people what they enjoyed and used this to plan activities, including gardening and an activity involving a lamb.
“Activities were being planned in line with people's wishes and interests.” from the report
Better quality monitoring
The provider had improved its audits and other checks since the previous inspection. These were being used to identify shortfalls and support further improvements.
“The provider was now using audits, conversations, surveys, observations and monitoring to effectively highlight shortfalls and drive improvement.” from the report
No registered manager
needs fixingThere was no manager registered with the CQC when inspectors visited. An experienced relief manager was managing the home while the provider recruited a new manager.
“The service did not have a manager registered with the Care Quality Commission.” from the report
Permanent staff recruitment
minorThe provider said recruiting additional permanent staff was a priority. Agency staff were used when shortages occurred, although the report says they were familiar with the home.
“The operations manager told us recruitment of permanent staff was a priority for the home.” from the report
- 01Who is currently managing the home, and has a registered manager now been appointed?
- 02How many permanent staff are currently employed, and when are agency staff used?
- 03How are pressure-relieving mattresses and cushions checked for the people who need them?
- 04How are care plans reviewed with residents and their families, and how are changes passed to staff?
- 05What activities are currently available for people living with dementia and for people with different interests?
This was an unannounced comprehensive inspection covering all five CQC questions, including the care provided and the premises. This explanation was written from the published report of 22 March 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Portcullis House
3 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- March 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 15 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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76 live-in carers within about two hours of Somerset
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Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
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