CQC report explained · a residential care home
What the CQC found at Portelet Manor Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2023
Portelet Manor Rest Home is rated Requires Improvement; inspectors found risks, consent records and management checks were not consistently handled.
This was an unannounced inspection on 28 June and 3 July 2023. One inspector spoke with people, relatives, staff and health professionals, observed care and checked care records, medicines records, staff files and management records.
The home was not always safe. Some risks were not assessed or managed properly, including risks of skin damage and risks linked to the stairs. Care plans contained inconsistent information, accident records were incomplete and medicine checks were not always done as required.
People were not always supported in line with the law when they could not make particular decisions for themselves. Mental capacity assessments and evidence about lasting powers of attorney were not always in place. Management checks did not identify these problems.
The overall rating changed from Good at the previous inspection in 2019 to Requires Improvement. The report says the provider took immediate action during and after the inspection, and CQC will continue to monitor the home.
Health support
Staff worked with health and social care professionals and made referrals when people's needs changed. Feedback said staff knew people well and contacted professionals promptly.
“The care home have generally a good understanding of their residents and work well in trying reduce people becoming distressed.” from the report
Kind and respectful care
Inspectors saw staff treating people with dignity and respect. People and staff described a kind and friendly culture.
“Staff interacted with people in a kind and considerate manner, treating them with dignity and respect.” from the report
Food choices
People were offered choices about food and drink, and staff understood guidance for people at risk of choking or needing a particular food texture.
“The food is very nice, they come round with the menu, and you can get what you want, day or night.” from the report
Fire safety improvements
The home had made changes to improve fire safety, including new firefighting equipment and personal emergency evacuation plans.
“The provider had installed new firefighting equipment, including an outdoor fire extinguisher and protective aprons to prevent the spread of fire.” from the report
Unmanaged risks
seriousTwo people's repositioning plans were not followed within the required timeframe, placing them at risk of harm. Some environmental risks and accident records were also not properly managed.
“People were not protected from avoidable harm, for example the assessments of 2 people at risk of skin breakdown had not been followed” from the report
Consent and capacity
seriousMental capacity assessments were missing or inconsistent. The home had not checked evidence that people consulted about best-interest decisions had the legal authority to do so.
“People did not always have the necessary MCA assessments in place as required.” from the report
Weak management checks
seriousAudits and spot checks did not identify problems with risks, medicines, consent or records. The home also did not record learning from incidents.
“Quality assurance systems did not always operate effectively.” from the report
Medicine audits
needs fixingPeople generally received medicines as prescribed, but medicine administration records contained errors that staff checks had not found. The provider was asked to improve its medicine management checks.
“We recommend the provider follows their procedure to ensure medicines management is safe and checks are carried out as planned” from the report
Staffing and activities
needs fixingSome people and staff said staffing levels did not always meet people's needs, including for showers, night-time support, activities, shopping and appointments. The provider said it had increased daytime staffing and introduced dedicated activity time.
“A staff member told us, "The staff ratio is too low. We all want to spend more time with the residents and doing activities but unfortunately, we just don't always get the time.” from the report
- 01How have you made sure every person's risk assessments and care plans are current and consistent?
- 02What has changed to ensure repositioning plans are followed and accidents or incidents are recorded and reviewed?
- 03How do you now complete mental capacity assessments and confirm lasting powers of attorney before making best-interest decisions?
- 04How are medicine administration records checked each day, and who is responsible for following up errors?
- 05How do current staffing levels cover night-time care, showers, activities, shopping and appointments?
This focused inspection examined Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 22 August 2023 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, June 2019
Portelet Manor Rest Home was rated Good; inspectors found kind, safe and personalised care, with some care records still being improved.
This was an unannounced inspection on 10 November 2018. It was the first inspection since the current provider took over in December 2017. Inspectors spoke with people living in the home, a visitor, staff, managers and a health professional. They also observed care and checked care, staff, accident, medicine and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were happy with their care. Staff knew people well, treated them with kindness and supported their choices, health needs, medicines, meals and activities.
The home had gone through changes, including three managers in the previous year. There was no registered manager at the inspection, but the new manager had started an application to register. Inspectors found that care records were being transferred to a computer system and some information was not yet recorded clearly.
Kind and respectful care
People said staff were kind and inspectors observed warm, caring interactions. Staff knew people's histories, interests and communication styles.
“We observed staff interacting with people in a caring and compassionate manner.” from the report
People felt safe
People said they felt safe. Staff understood individual risks, safeguarding procedures and the steps needed to reduce risks.
“People told us they felt safe and visitors shared this feeling.” from the report
Enough trained staff
Inspectors found enough staff to meet people's care and social needs. Staff had appropriate recruitment checks, training and support.
“There were enough staff on duty to meet people's needs.” from the report
Personalised support
People were supported to make choices about their care, food, clothing and activities. Care plans included personal preferences and communication needs.
“People were supported to live their lives the way they chose and staff respected their choices.” from the report
Good oversight
The provider used monthly visits, audits and surveys to monitor quality and identify improvements.
“There were systems in place to monitor and improve quality including seeking the views of people and relatives.” from the report
Care records needed clearer information
needs fixingSome information about risks and care needs was not clearly recorded in care plans. Managers addressed examples during the inspection, and the new manager had started a wider review.
“Some information was not held clearly in people's care plans.” from the report
No registered manager
minorThere was no registered manager when inspectors visited. The previous manager had resigned and the new manager had begun an application to register.
“There was no registered manager in post.” from the report
Recent management changes
minorThe home had experienced a new provider and three managers in the previous year. Inspectors said people and staff were positive about the current arrangements.
“Portelet Manor Rest Home had gone through a period of change with a new provider and three managers in the last year.” from the report
- 01Is the manager now registered with the CQC, and who is responsible for the home if they are not?
- 02How do you check that risk information, such as pressure sore and falls risks, is clearly recorded in each care plan?
- 03What changes have been made to the care planning system since this inspection?
- 04How are activities matched to each person's interests and preferences?
- 05How do you monitor staffing levels when residents' care or social needs change?
This was an unannounced inspection of the overall service and covered all five CQC questions. This explanation was written from the published report of 26 June 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 Portelet Manor Rest Home
2 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2019GoodSafe: GoodEffective: GoodWell-led: Good
- December 2017
Registered with the Care Quality Commission on 1 December 2017.
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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