Portcullis House

We found the following examples of good practice.

Relatives and friends were able to visit in a specially designed area which was a specially divided conservatory where people living in the service sat one side of a clear 'wall', while their visitors sat the other side. Visitors were able to enter directly from the carpark and therefore did not have to come through the service. Visits were timed to ensure there was sufficient time to clean the areas before another visit commenced.

Staff also supported people to keep in regular contact with friends and families through telephone and video calls.

Each person had their temperature taken twice daily and staff were vigilant about looking for any signs or symptoms of Covid-19.

There were weekly multi-professional meetings held via social networking with a GP, a pharmacist, district nurse, physio and a social worker. This has supported the service to get advice about concerns in a timely manner.

People’s experience of using this service:

Since the last inspection the provider had made improvements to the care provided to people and the effectiveness of their quality monitoring systems.

Portcullis House provided a comfortable friendly environment for people to live in. Visitors were always made welcome and people told us they felt at home.

People felt safe at the home and with the staff who supported them. The risks of abuse to people were minimised because the provider had systems and processes in place to protect people. Staff treated people in a non-judgemental way and respected them as individuals. Any concerns regarding poor practice by staff was dealt with promptly to make sure people were not put at risk.

People were cared for by staff who had the skills and experience to meet their needs. Staff had received training to make sure they were able to meet people’s specialist needs. In the area of the home which cared for people who were living with dementia, staff interacted well with people which created a relaxed and calm atmosphere.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People told us staff encouraged them to be independent where possible.

People told us staff were kind and patient and we saw this during the inspection. People were assisted in an unhurried manner and their dignity was respected.

People could choose to socialise with other people or remain in the privacy of their personal rooms. During the inspection we saw some people enjoyed laughter and friendly banter with staff. Staff respected people’s choices.

People’s nutritional needs were assessed and met. People told us there was always a choice of meals and they could request alternatives to the meals on the menu. People’s specialist diets were catered for.

Each person had a care plan which identified their needs and gave staff guidance about how people wished to be cared for. This helped to make sure people received support in accordance with their needs, preferred routines and lifestyle choices.

Staff had a good understanding and knowledge of the people who lived at the home. This enabled them to provide care and support which was person centred.

People lived in a home where the provider was committed to seeking their views and making on-going improvements in line with people’s wishes.

Rating at last inspection: Requires improvement (published 29/03/2018)

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions, safe and well led to at least good. An action plan was received by CQC and at this inspection we saw that actions planned had been put into practice.

Why we inspected: This was a planned inspection based on previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Portcullis House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The home specialises in the care of older people including people who are living with dementia. Part of the home, Rose Garden, is accredited with the Local Authority to provide specialist residential care (SRC) for people with dementia. A mental health nurse from a local healthcare trust supports this part of the home.

CQC regulates both the premises and the care provided. The inspection team looked at both during this visit. The service is registered to provide care and accommodation to up to 44 people. At the time of the inspection there were 37 people living at the home.

There was a manager in post at the time of this inspection. The manager was recently recruited and had submitted an application to become registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection, we identified that the provider needed to make improvements to ensure staff cared for people safely. We identified concerns around risk management in relation to pressure damage to people’s skin. We requested staff take immediate action to reduce this identified risk. In another instance, staff had not completed a malnutrition universal screening tool (MUST) to establish a person’s nutritional risk correctly. We raised this at the time of the inspection and staff adjusted the information immediately.

Current governance arrangements had not consistently identified shortfalls within the service. Internal governance systems were either not in place or had not been effective. Care records did not show people’s up to date needs. For example, one person had an updated risk assessment regarding their mobility needs. The outcome of the assessment showed that due to deterioration in the person’s mobility they required staff to assist them to move using a mechanical hoist. The care plan had not been up dated to reflect this change meaning staff did not have easy access to information about the person’s current needs.

There were a number of vacant staff posts. This led to the high use of agency staff. The provider did not consistently align the induction to the Care Certificate. Supervision was not always completed in line with the provider’s policy that staff should receive supervision four times a year.

The provider did not enable people to carry out person centred activities. Care plans did not identify people’s hobbies and interests. Activities that staff did deliver were not consistent. We observed staff leaving the room half way through an activity, which meant people were left with nothing to do.

We have recommended that the provider undertake a review of the current activity provision.

Leadership was not robust. Current governance arrangements had not consistently identified shortfalls within the service. The provider had appointed a new manager who had been in post for two months at the time of the inspection. The manager had a commitment to improving the care and support people received. However, they had not fully implemented the initial audit or shared with the team any objectives agreed. This meant the team found it difficult to know what a priority was.

People did tell us they felt safe at the service and were positive about staff. There were systems to support people in the event of an evacuation of the service. Most people gave positive comments about the care they received. In general, access and referrals to healthcare professionals was timely. Staff supported people in an environment where the adaptation and design was appropriate. There was space for people to sit outside in the summer.

We observed care staff addressing each person by name. Staff told us, “The most important people here are the people who live at the home.” “We have to look after them as best as we can, we can go home at the end of our shift, they can’t they are here all of the time.” Staff appeared kind and interacted with people well. People told us they would be comfortable raising a concern or making a complaint if they needed to.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Portcullis house is registered to provide care and accommodation to up to 44 people. The home specialises in the care of older people including people who are living with dementia. Part of the home, Rose Garden, is accredited with the Local Authority to provide specialist residential care (SRC) for people with dementia. This part of the home is supported by a mental health nurse from a local healthcare trust. At the time of the inspection there were 32 people living at the home.

The last inspection of the home was carried out on 8 May 2014. No concerns were identified with the care being provided to people at that inspection.

There is a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager was qualified and experienced to manage the home. They were well respected and people felt able to discuss their care and share concerns with them.

The provider was experiencing difficulties with staff recruitment and there were a number of vacant staff posts. However this was being well managed to ensure it did not have a negative effect on people’s care. People told us there was always staff available to them when they required support and that staff answered requests for help promptly.

People received effective care and support to meet their needs and advice was sought from healthcare professionals when required. The staff responded to changes in people’s care needs but care plans were not always up dated to reflect changes. This could potentially place people at risk of receiving care that did not meet their current needs.

People felt safe at the home and with the staff who supported them. One person said “I have more confidence now I am living here. I think it’s because there’s nothing to worry about and I feel safe day and night.” People were complimentary about the staff at the home and found them to be kind and caring.

Risks of abuse to people were minimised because the provider had a robust recruitment process and staff knew how to report any concerns.

Staff had the skills needed to effectively support people including the specialist skills required to care for people living with dementia. Staff enabled people to maintain their independence where possible and to make choices about their day to day lives. People thought staff were well trained and competent in their roles.

People’s nutritional needs were assessed to make sure they received a diet in line with their needs and wishes. At lunch time people were able to make choices about the food they ate and portion sizes. Where people were unable to make a verbal choice they were shown the selection of meals to help them to choose. People received the help they needed to eat their meal. Staff discreetly encouraged people and offered physical assistance if people were seen to be struggling.

There were ways for people and their representatives to be involved in planning their care and to make suggestions about the running of the home. Suggestions made were acted upon where possible.

The registered manager and provider had a quality assurance system which included observational audits and themed conversations. Where shortfalls in the service were highlighted action plans were put in place to make improvements.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

This is a summary of what we found

Is the service caring?

People told us that received very good care, that 'they are everything I could ask for' The atmosphere was relaxed, no person was rushed and staff answered call bells instantly.

People told us the staff always had time for them and listened with patience if they had trouble expressing themselves. We saw how staff sat down to talk with people, ensuring sufficient time was given to each person. We were told that staff listened to people and their relatives, this meant they understood how to give individualised care.

We observed how staff responded quickly and in a respectful manner to peoples care needs, such as giving assistance at meal times. Staff ensured privacy when discussing individual needs and when giving personal care.

We observed staff assisting people and noted that at all times they were treated with respect. We saw that people were given support when required, but also enabled to remain independent.

A relative told us they had been 100% satisfied with the care given to both their parents and the sensitivity and help shown had been 'exemplary.'

Is the service responsive?

The service was part of the local community, well positioned within the town and involved the community in their activities.

We saw how in the smaller unit they made good use of sensory decorations that people could touch and handle. We saw how memory boxes had been used to enable people to recognise their own rooms and so help with orientation.

We saw evidence of how the service responded quickly to a person's changing needs, how they facilitated changes and ensured any recommendations were carried out. They had a close link with other professional services and good referral and assessment system in place.

We saw that the annual questionnaires were important in remaining responsive to people's well-being. The complaints procedure was in place, but we were told 'If I have a complaint I will tell the manager and I know it will be acted upon, but I have nothing to complain about'

Is the service safe?

People were treated with respect and their dignity ensured by the staff. We were told by people they felt safe and secure at all times. We were told that "Here I have no worries anymore". Staff understood how to safeguard the people they supported

The systems in place ensured that managers and staff learnt from events such as accidents, incidents, complaints and investigations, thus reducing the risks to people. The service strived to continually improve the service given to the people.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies to care homes. The Deprivation of Liberty Safeguards is in place to protect people's human rights.

There were proper policies, procedures and full training in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards, with staff showing good understanding of when and how an application should be submitted, this means people will be safeguarded as required. We saw that staff knew about the Whistle blowing procedure and how to report any cause for concern.

A comprehensive training programme was in place for all staff, including Manual handling, Dementia Awareness , communication and Safe handling of medicines. This ensured the staff had the knowledge to provide safe care for people.

Equipment used was well maintained and safe, with staff fully trained in the use, this reduced the risks to people. The registered manager ensured there was sufficient staff on duty, with the necessary qualifications and skills required to meet the needs of people. The rota was continually monitored to account for changing needs and staff requirements, with capacity to respond to unexpected circumstances that might occur.

Recruitment practice was safe, with policies and procedures in place. If disciplinary action was required then action was taken immediately and thoroughly, thus ensuring people were protected from unsafe practice.

Is the service effective?

People were involved in assessing their health and care needs and in the writing of their care plans. Their specific needs were identified in the care plan and information gathered from other professionals and relatives to ensure their care needs were met and the individual was at the centre of the care provision.

Dietary needs were assessed and special diets catered for in an imaginative way, ensuring that everyone could enjoy a satisfying and enjoyable meal time.

Portcullis House has two areas, which although they run independently share staff and have some joint activities. The smaller bedded area accommodates people requiring more support owing to their dementia. The service took account of the needs and abilities of people, ensuring the environment was safe by use of signage and a sympathetic layout. This enabled people to remain active and independent. One person told us their relative "enjoyed being able to do ordinary things, like drying the dishes"

Families and friends were welcome to visit at any time.

Is the service well-led?

The home is run by a manager who is registered by the Care Quality Commission.

The service is well run, with good support from the parent company. We saw evidence of this in action. Staff told us they felt confident that any problems they had could be shared with the manager.

People using the service told us they never felt at any time they were alone, relatives told us the management were approachable and felt the service was well run.

Staff told us that they felt the method of disseminating responsibility through the staff was good. There was always a person to refer to even if the manager was not available and they would not be ignored. We were told that "The managers door is always open and even if they are busy will always find time to talk to you"

We saw evidence of how various quality assurance systems were in place and used to ensure a good quality of service.

We saw how management worked well with other agencies and professionals, ensuring people received the care they needed.

Some of the people who lived at the home were unable to fully express their views to us verbally because of their dementia. Therefore in addition to speaking with people who used the service, we also observed care practices and spoke with staff.

People we spoke with were very happy with the care and support which they received. One person told us 'I'm quite happy living here and I feel well cared for.' We noted that everyone was well dressed and well presented which demonstrated that staff took time to assist people with personal care.

There was a relaxed atmosphere in the home and people appeared very comfortable with the staff who supported them. Throughout the day we observed, and heard, pleasant and caring interactions between staff and the people who lived at the home.

All areas of the home were well decorated and maintained. All communal areas were accessible to people with all levels of mobility including wheelchair users. There was a variety of communal areas including well maintained gardens. This meant that people were able to choose where they spent time.

There were systems in place to effectively monitor the quality of the service offered and ensure the safety of people who lived at the home.

Some people who lived at the home were unable to express their views verbally. We therefore spent time observing practices and talking to staff, as well as speaking with people who lived at the home.

People who were able to express their views said that they felt very well cared for. Comments included; 'they look after us very well' and 'anything you want you only have to ask, the staff just want you to be happy.' One person told us 'it's a lovely place to live and we all have lots of laughs.'

People who were unable to verbally communicate with us appeared very content and cheerful. People were well dressed and presented which demonstrated that staff took time to assist people with their personal care.

Throughout the day we observed that staff appeared competent and cheerful in their jobs. One person who lived at the home said 'They know what they are doing and are really quite nice.'

No one who lived at the home raised any concerns about the care which they received. Most people we spoke with said that they would be comfortable to discuss any concerns with a member of staff. Some people said that if they had any complaints they would ask a relative to raise the matter with staff.