Portsdown View

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

At the start of our assessment in March 2024 we found people were not always protected from avoidable harm. Risks to people had not always been assessed, monitored, or mitigated effectively which sometimes led to reoccurring incidents. The provider had a safeguarding policy in place, however, this had not always been followed effectively which meant people were not always being protected from abuse. People did not always receive their medicines safely. We identified numerous shortfalls with medicines processes and risk assessment. However, the provider was responsive to our feedback and had made improvements to all the areas of concern during our the period of our assessment. These improvements need time to embed into practice. Staff had been recruited safely with relevant checks taking place to ensure they were suitable to work in a care environment.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe, were happy with their care and said that staff were kind and caring. Comments included; “I feel very safe, yes.” “They really care.” “Yes, I feel totally safe.” A relative told us, “They are aware of mum’s lack of movement and there are always two staff getting her up.” People and relatives told us they felt able to raise concerns with staff. One relative told us, “We were concerned management kept changing and raised it at a relatives meeting” but now felt things were more settled.

During our site visits in March 2024, staff told us they had received training in safeguarding people from abuse and knew how to identify and report a concern. However, there was a lack of knowledge about Deprivation of Liberty Safeguards (DoLS) amongst the care staff. All but one member of staff was unaware of who had a DoLS in place and what this meant. Most staff also lacked knowledge of the Mental Capacity Act (MCA) and what this meant for people in their care. The provider was responsive to our concerns and improvements had been made during the assessment. At our site visit on 27 June 2024, we found there had been an improvement in staff knowledge and the implementation of safeguarding, mental capacity and DoLS. Whilst improvements had been made, these need time to embed into practice.

During our site visits in March we observed staff did not effectively monitor communal spaces in the home to ensure incidents, which had been previously identified, did not reoccur. This put people at risk of abuse. During our visit on 27 June, we observed staff were more aware of the need to carry out checks on communal spaces within the home. This needs to be sustained and embedded in on-going practice.

At the start of our assessment, we found safeguarding incidents had not always been identified and reported to the local authority and the commission. We found safeguarding incidents were not always reviewed or followed up. For example, a staff member reported an incident between 2 people, and this was not identified by management until another incident between the 2 people occurred. During our site visit on 27 June safeguarding procedures were robust, and incidents had been reviewed and any learning communicated to staff. This now required time to embed into practice.

Most people told us they felt involved in managing risk. Comments from people and relatives included, “They are safety conscious,” and “They’ve identified mum’s mobility is decreasing so now she has a hoist.” Another person told us staff knew they were at risk of falling so ensured she had her commode ready at night. One person did not think they had been involved in discussing risks but had no concerns.

Staff understood the importance of positive risk taking, speaking to people about risks and helping them to make decisions. Comments included, “I would assist them but try to help them maintain their independence. We have [a person] who can only walk so far, so we let them walk but we follow behind with a wheelchair.” And “I would give the resident all the information they needed to be aware of the risks involved. I would never make them go with the choice I am suggesting, it is still up to them. I would document the conversation and put interventions in place, for example, more staff monitoring.” Managers gave examples of people being involved in risk management and respecting their decisions where they had capacity. For example, the use of an air flow mattress was recommended for one person, however they did not like it and asked for it to be removed. This was documented in the person’s care plan and risk assessment.

Staff were rushed at times, and this impacted their ability to observe people in line with risk assessments to keep them safe from abuse. At our site visit on 27 June, we saw there were more staff on shift to be able to monitor areas of the home to ensure people’s safety.

Systems to identify and manage risks were not always effective. Risk assessments sometimes lacked detail and were not robust. This meant that actions to reduce risk had not always been identified. For example, to help prevent falls or reduce the risk of pressure wounds. In most cases there was no recorded evidence on care plans and risk assessments that people had been involved in the reviews. Audits of risk assessments and care plans had not identified the issues we found during our assessment, and where they had, not all issues had been addressed. The provider was responsive to our concerns. Care plans and risk assessments were being re-written. The provider was working with relevant professionals to ensure learning and to receive support during the process. This learning now needs to be embedded into care practice.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt there were enough staff on duty most of the time. One person said, “The staffing levels are pretty good.” Another person told us, “On the whole, yes.” However, they explained on one occasion a manager had had to come back to give medicines in the evening because there was no one else to do it.

At our site visit in March 2024, most staff were not happy about staffing levels and told us there were times when they were short staffed which limited the time they could spend with people. Comments included, “They are taking staff from other departments. If we need care staff they take them from housekeeping.” “We’re short staffed quite a lot but [management] say we’re not.” “Residents complain because they are waiting for their wash in the morning. People are waiting to go to the toilet. I would say sometimes residents are neglected because of lack of staff.” At our site visit on 27 June 2024, there had been an increase in people living at the home. Staffing had increased in line with this. Staff told us they felt staffing had improved. The provider told us they trained staff in other departments to deliver care. This avoided the use of agency staff. During our visits in March 2024, most staff told us they had received on-line and face to face training. However, we were not assured training was always effective as we found gaps in staff knowledge. Staff had also not always received training in specific topics related to peoples’ individual needs, such as the use of a rescue medication for allergic reactions and diabetes. During our visit on 27 June 2024, we found staff training had improved. There had been a robust programme of training for staff, some of which had been delivered by local statutory care teams. This needs to embed within staff practice and understanding.

During our site visits in March 2024, we observed staff were very busy and rushed. Staffing levels and deployment had not considered the size and layout of the home, which meant at times there were not enough care staff in all areas of the home to support people safely. During our site visit on 27 June, we observed there were more staff on shift and staff were not so rushed.

During our visits in March, we found individual dependency assessments did not link directly to the tools used to assess staffing. The nominated individual explained they worked on ratios depending on occupancy. The tools had not identified peak times where more staff might be needed, such as morning personal care and breakfast. It also did not consider the size and layout of the building. At our site visit on 27 June, the nominated individual told us they were developing a new dependency tool which would better reflect people’s individual needs and preferences. The service had a robust recruitment process in place. Staff were only appointed after they had successfully completed an interview, references were received and enhanced DBS check obtained.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were mostly happy with the way staff managed their medicines. One person said it was discussed when they moved into the home. Another person said, “They never miss it. They ask me where I want them, get me a drink and watch me take them.” Another person was happy overall but on the day we visited, they told us staff could not find their inhaler and had given them a nebuliser instead.

Staff told us that there was no written handover sheet at the start of a shift that would tell them if peoples’ health or medicine needs had changed. Information therefore had to be searched for in an individual’s care records. Staff told us that they were not trained in all required aspects of medicines administration and we could not find training records for 3 staff. Following feed back, the provider sent us training records for 2 staff but not the third. When auditing self-administered medicines, staff told us they didn’t always take additional action when identifying discrepancies, to gain reassurance that the person was self-administering as the prescriber intended. During our site visit on 27 June, we found the provider had taken action during the assessment to address these shortfalls.

At our visits in March, we found systems and processes to ensure safe management of medicines were not always followed or effective. When people were prescribed ‘when required’ medicines, guidance for staff did not contain enough information to support them to know how and when to administer these consistently. Risk assessments were not always in place for people. For example, when people were prescribed blood thinning medicines, which increases the risk of bleeding. Medicines related incidents were recorded and reviewed by managers. However, there was no evidence of shared learning or actions taken to prevent reoccurrence. Medicine audits were carried out. However, the audits failed to identify concerns related to medicines management we found during the assessment. The service had begun to respond to some of the concerns raised and during our visit on 27 June we found there had been significant improvement in the management of medicines. This needs to be embedded and sustained in practice.