Portelet Lodge Care 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

Well-led – this means we looked for evidence that provider leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the provider management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to good governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider encouraged a positive culture, staff and leaders were not always equipped to ensure this intended culture was delivered in practice.

Staff told us they felt listened to and able to provide feedback to the management of the provider. Staff felt part of a team and told us the culture at the provider was positive and inclusive. A staff member said, “I feel that I'm able to speak up about any concerns or suggestions at work. I believe I am heard because managers listen and give feedback or even take actionwhere needed.”

Whilst the provider was responsive during the inspection and started to make necessary changes in response to our feedback, they were not proactive in identifying shortfalls in care delivery and relevant documentation.

Management demonstrated compassionate and inclusive leadership by listening to staff concerns and providing appropriate support. Whilst the management team were seen as approachable, they demonstrated lack of knowledge and understanding of the requirements of the regulations.

Staff confirmed the management were approachable and supportive. One staff member said, “I know my manager, she is always punctual at work, dedicated, compassionate, approachable, always supports staff in every capacity and the office is always open to all staff.” Another staff member said, “I feel that I'm able to speak up about any concerns or suggestions at work. I believe I am heard because managers listen and give feedback and take actionwhere needed.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they knew how to and felt encouraged to speak up. Staff knew how to report concerns to external organisations, such as CQC and the local authority. One staff member said, “If I suspected abuse, I would report it immediately to senior management, the safeguarding lead, or the manager. If needed, concerns could also be reported externally to safeguarding authorities, the local authority, or the CQC.” Another staff member told us, “I feel comfortable speaking up. The workplace encourages open communication, and I believe my voice is heard.”

The provider had up to date policies in relation to safeguarding and whistleblowing.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they felt their workplace was inclusive and fair. One staff member told us, “The manager models inclusive behaviour, all nationalities are welcome, embraced and everyone is treated equally and fairly. There is no discrimination.” Another staff member said, “I feel the workplace is inclusive and promotes equality and diversity. Staff are treated fairly regardless of background, religion, gender, or culture.”

The provider had an up-to-date equality, diversity and human rights policy and provider relevant training to staff. Staff had the opportunity to share their views with the provider via a survey. The feedback was mostly positive.

Staff told us they were supported to complete additional training and encouraged to progress if that is what they chose to do.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Provider’s governance systems were not always robust and failed to identify shortfalls found at this inspection.

Care plans and risk assessments were regularly reviewed, however they often contained contradictory information. Some people’s SALT requirements were not clearly communicated with staff or recorded. This meant staff were not always provided with up to date and accurate description of people’s needs and risks in relation to their care and treatment.

Systems in place to monitor people’s weights and mattress pump settings were ineffective. This put people at risk of avoidable harm.

System to determine the number of staff required in relation to people’s needs was completed incorrectly and at the same time indicated more staff were needed at certain times of the day than were scheduled to work.

The fire risk assessment in the provider indicated several works needed to be completed. These were done by a qualified contractor. There was no effective oversight in place which meant some actions were still outstanding.

The provider had up to date policies regarding CCTV usage in the provider. However, they did not follow them or complete relevant documentation.

In response to our inspection feedback the provider addressed some of the shortfalls and started to make changes to their systems. The improvements made needed to be embedded into practice and sustained.

The provider understood their duty to collaborate and work in partnership, so providers work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Records showed the provider maintained regular communication with a wide range of health and social care professionals to ensure people’s needs were being met.

A health and social care professional told us they felt staff knew how to assess people’s wellbeing and had the necessary training to take simple observations of people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Our inspection found widespread and significant shortfalls which were not identified or addressed through the provider’s quality management systems.

The provider was responsive during our inspection and started to make changes to their systems and processes. However, these were new systems and processes which needed time to be embedded and sustained.