Port Regis

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

The service was in breach of legal regulation in relation to governance at the service.

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.

There had been some positive changes to the management of the service which was improving the culture and direction of the home. The provider was strengthening a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff commented about the improvement in the service.

The atmosphere during our inspection was warm and friendly, staff were attentive to people. The provider was visible and worked closely with the registered manager to support the home.

Leaders had not always demonstrated the skills, knowledge, experience and credibility to lead effectively. During this inspection we found the service was in breach of the legal regulations in relation to safe care and treatment and good governance. There had been some recent changes in the management structure at the service to support better service delivery. The registered manager and provider worked closely together to run the service, they had been reflective and had made some changes to improve the quality of the service delivered. However, they had not identified all of the shortfalls that we found at this inspection to drive improvement in all areas and ensure compliance with the regulations.

People and relatives were positive about the management and felt they were approachable and responsive. A relative told us, “If I had any problems I would go to the owner. The owner is around which is reassuring.” Most staff also felt they were approachable, although some had fedback that their concerns were not always acted on.

The registered manager was part of a local registered manager group, and got support from other local managers to continue to support their understanding and develop their skills and knowledge.

Staff did not always feel that action would be taken when they spoke up and that their voice would be heard. Although staff told us, “I know how to whistle blow.”, we received mixed feedback from staff in relation to feeling like their concerns were acted on. Some staff gave examples of personal or work-related issues they had raised and told us they did not feel these had been addressed to their satisfaction. However, other staff members gave an example of when they had shared concerns with the management team and these were addressed.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Equal opportunities monitoring was in place at the recruitment stage. Staff completed training on equality, diversity and human rights to promote good understanding and practice within the service.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. Although there were systems and processes in place to support the management of the service; these had not always been effective.

The provider’s quality assurance processes were not effective as they had not picked up shortfalls we identified during this inspection. For example, audits of people’s care records had not identified shortfalls in assessing risks and the lack of guidance within care plans. In addition, the system for monitoring whether care record reviews had been completed had not been robustly applied. Staff had recorded a person had had a care review for two consecutive months. However, there was no review recorded within the person’s file. The provider took action immediately and implemented a new system ‘Resident of the day’ to ensure monthly reviews took place and a review checklist had to be signed to confirm staff reviewed each section as required. We will check that an effective system is in place and embedded at our next inspection.

The recent medicine audit had also not picked up on the stock concern we identified during this inspection. The registered manager implemented an additional weekly check following the inspection in order to more robustly assess the safe delivery of medicines and allow for issues to be identified in a timely manner.

Daily logs of people’s care were not always detailed to demonstrate that care was being delivered as care planned. For example, a person was recorded as asleep during their night checks however during the daily meeting staff reported the person had a bad night and had been in the lounge dozing. This meant the provider did not have robust oversight of the care being delivered.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider had arranged for specialist training to be delivered by other healthcare professionals to support staff to better meet people’s needs. Professionals provided positive feedback about the partnership working at the service. A professional said, “I have no specific issues attending to clients[needs]. The management always make sure I have help and assistance on a regular basis.”

The provider maintained strong links with the community and involved them in the service. Food was sourced from the local butcher and greengrocer for example. Outside entertainment was brought into the service to ensure people remained engaged. The provider also was proud of their partnership working with the nursery and scouts who came to see residents. During our inspection we saw people watching and enjoying seeing the children, playing in the nursery garden.

The provider had not always focused on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice.

The service was in a period of transition when we carried out our inspection. The changes to the management structure at the service were having a positive impact however there were still some areas for improvement. Staff did not always feel supported to carry out their roles and did not always feel like their concerns in relation to this were acted on. The provider addressed this following the inspection.

Improvements were needed in relation to the record keeping and governance to ensure all systems and processes were operated effectively to support people’s safe care. The management team had begun to take action following the inspection to address issues found and had made changes to their governance system to prevent similar issues from occurring again in the future. However, at this time these needed to be embedded effectively.

The provider had plans to digitalise the service and felt this would help with clearer care planning and keep information up-to-date and easily accessible. They felt this would also help to improve aspects of governance such as auditing.