Portobello Place

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• 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

We identified two breaches of the regulations, including safe care treatment and a failure to notify CQC of reportable events. Staff did not consistently protect people from abuse and improper treatment. They did not always identify allegations of abuse or make referrals in line with policy. Staff did not always assess risks to people's health and safety or mitigate them where identified. The management of hygiene and control of diseases failed to protect people from the risk of harm. Furthermore, information shared with us by the local authority safeguarding team, demonstrated the provider had failed to inform us of accidents and incidents that had occurred in the service. You can find more details of our concerns in the evidence category findings below.The provider informed us after the inspection that staff had been trained in safeguarding procedures.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they were not always confident all the staff supported a learning culture. We found people living on the second floor of the home had fewer positive experiences than those living on other floors. People who provided positive feedback told us they had their concerns heard and action was taken to prevent a re-occurrence. However, other people told us they had mentioned concerns to staff and had received no response. We provided some feedback to the registered manager who took action to address the concerns. Some people were disappointed in the lack of response from the staff to their questions or concerns. Comments included , “I asked one of the senior medicine girls, but I haven’t heard a thing”, “I see the same problems and the same problems are seen and expressed by the other people that sit at my (lunch) table” and “I told four or five carers but no one really seemed interested.” Relatives told us they had either made complaints or requested meeting with the registered manager to ensure changes occurred in their family member’s support. Many relatives told us they did not believe staff had a good understanding of people’s needs who were living with dementia. Comments included “We do think there has been a general lack of understanding of how to care for [people] which has an impact on their safety and wellbeing.” We reviewed the staff training records which showed 72% had received training in dementia awareness, which suggests the application of the training into practice was not obvious to some relatives.

We received mixed feedback from staff. Many care staff were reluctant to offer their views. We discussed this with a member of the providers’ people management team. Some staff felt there was an open learning culture and other staff felt they were limited in what they could report and to whom. Staff were aware of the need to report any accidents and incidents. The registered manager told us they had recently introduced a ‘5-why’s’ approach to incident analysis in an attempt to improve learning.

There were processes in place to record and report accidents and incidents. People’s accident and incident forms recorded events such as falls, unexplained bruising, and people’s behaviours when they were distressed. However, not all had been routinely reported to the relevant external organisations. This had been previously highlighted by the local authority following the contract monitoring assessment completed earlier this year. The provider’s policies and procedures for reporting concerns had not been followed on every relevant occasion.

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 living in the home, comments included, “Yes I certainly do feel safe, oh yes, if I didn’t I would say something”, “Yes I do feel safe, I am not ill, I don’t take medicines but I do feel physically safe” and “I do feel safer and at least I have someone to say ‘hello’ and ‘good morning’ to.” Some relatives told us they were not entirely sure their family member was safe. Comments included, “I don’t think [family member] is 100% safe” and “We only feel [family member] is about 75% safe here.”

We received mixed feedback from staff about how well they were equipped to ensure people’s safety. Staff told us they had received safeguarding training. However, some staff told us this was only after a visit by the local authority contract monitoring team. Some staff in support roles had not received any training on how to recognise abuse.

We observed staff supported people in a safe way. We found staff promoted safety by checking on people throughout the day and night. We found people were not subject to unnecessary restrictions on their movement. Where restrictions were in place these were lawful. For instance, lap belts or locks on doors.

The provider had a safeguarding policy, which directed staff on the process for dealing with and reporting safeguarding concerns. However, when we looked at daily records, we found staff had recorded incidents between residents, and unexplained bruising. These had not been reported as safeguarding concerns to the local authority. Most staff had received safeguarding training. The learning from the training was not applied to the care being provided. Although incidents were observed, there was not always a follow-up or referral to the local authority safeguarding team or CQC.

We received mixed feedback from people and their relatives. People told us they felt risks were managed in the home. One person told us “Yes, I do feel very safe living here, probably mostly because I feel secure, I know there are fire regulations and that everything like that is looked after too.” Staff reminded other people how to keep themselves safe when using their mobility equipment. Relatives told us they did not always feel risks to people were professionally managed. One relative told us how they were concerned about their relative becoming dehydrated. They were admitted to hospital with dehydration. Another relative told us how they were concerned their family member’s health had deteriorated due to poor care and a lack of management oversight.

Staff who provided feedback told us they knew risks to people were assessed however, they told us they did not always have time to read care plans and risk assessments. This placed people at risk of receiving inappropriate care. The registered manager told us care plans were available for staff on electronic handheld devices and that staff had time during their shadowing and induction to read care plans.

We found where people’s care plans stated they were at risk of dehydration and needed their fluid intake to be monitored this did not always happen. People’s fluid monitoring records failed to demonstrate they had been adequately supported to reach their daily fluid target. A consequence of dehydration is increased risk of falls which happened to one person. Healthcare advice was to ensure the person was supported with fluids post fall. Records relating to the person’s fluid intake following the fall failed to demonstrate they were offered the recommended daily fluids and there was no evidence this had been escalated. A hot water dispenser within the unit for people living with dementia was hot to the touch and was able to dispense hot water freely. This meant people were at risk of scalding. The registered manager told us they delegated the responsibility for the management of this risk. However, we found a risk assessment completed by the registered manager which stated a fob should be used to prevent people from dispensing hot water. This was not in place. We discussed this with registered manager and asked them to take immediate action to prevent scalding. The registered manager confirmed with us action had been taken. We observed a previous ‘5-why’s' investigation into a person ingesting hand cream had identified the need for some people to not have access to substances which may cause harm from ingestion. We observed people were still at risk of ingesting non-edible items as these were freely accessible. This left people vulnerable exposed to the risk of harm.

Based on our observations and feedback from staff and people, the systems in place for managing risk did not always involve people. Where people lacked the ability to manage risks independently, it was important staff recognised risks and supported people to manage them. For example infection control risks. We found this was not always happening.

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 gave us mixed feedback about the staffing levels and staff deployment. However, the main concern was staff shortages and the knowledge and familiarity of staff. Without exception people told us there were too few staff especially at night-time. People told us “I think that they are very short staffed”, there are definitely not enough staff and there are not enough at night and yet there are lots of levels of management”, “I think there are too few carers, you can sense that they are under pressure a lot of the time” and “There is a shortage of staff, there doesn’t appear to be many on at night, if we had more [staff] overall it would help.” One more person told us “Even with the staff shortages you will never guess that they all had training sessions last week, there was no one ‘on’ at all.” Another person told us their view of staffing, “It is difficult to know for sure, but I would say that they are usually understaffed, you certainly see lots of new ones [staff].” The person followed this up, “The theory was that you had a key worker and had an allocated night worker, the night worker who never spoke to me because I was asleep. I don’t seem to have a key worker now.” Relatives told us they had concerns about staffing levels. Comments included “There are sometimes limited staff”, “There are often not enough staff, and we hear buzzers going unanswered for ages”, and “Weekends are often temporary staff and they have no understanding of [family member] needs.” People gave us mixed feedback about how quickly the call bell was answered.

Staff who provided feedback told us they were recruited safely. However, some were concerned about the level of induction into their role and the quality of supervision meetings with a line manager.

On the first day of the site visit, we observed very few positive interactions between staff and people. Staff were focused on task-based interactions with people. We did not observe many meaningful conversations between staff and people. We provided this feedback to the registered manager at the end of the day. On the second site visit day, we observed more interactions between staff and people. We observed, people who were previously in their room for meals were supported to communal dining areas. This resulted in a busy and loud atmosphere in one dining room. We discussed this with staff and relatives who were present, and comments included “I think it was for show” and “More people have been bought to the dining room today.” On the second day we observed meaningful interactions between people and staff. We saw staff took an interest in people’s wellbeing and checked in with them when passing them in the corridor. One person’s face lit up when a member of staff came to their room, they told us “She’s [member of staff] is lovely.”

The provider had systems in place to ensure safe recruitment processes were followed. This minimised the risk of unsafe staff being employed. Staff received supervision and appraisals, this encouraged and supported staff with their day-to-day work and their professional development. However, feedback from people and relatives informed us there was a staff shortage which impacted on the care provided. Comments included “There is a high staff turnover, so we really have very little trust in them.” Another person told us “Since 2021 when the Manager left there have been lots of issues. From a safety aspect there were not enough staff, and the staff turnover was very high. This resulted in people having to wait for care, care plans were not in line with individual needs and staff had limited understanding of people’s specific needs. The registered manager informed us there had been high turnover previously, but the staff retention rate had been improving since the end of 2023. We also received feedback from an external professional who expressed a concern about staffing levels. Following the site visits, we discussed the concerns about staffing with the provider. They told us they were aware of historic concerns and had reviewed staffing numbers. We were informed by the senior managers; the staffing levels have been increased because of feedback from the relatives and this is checked weekly by the senior managers to ensure the safety of the service users. The provider was confident the staffing numbers were sufficient. A clear dependency tool was used to calculate staffing levels within the home.however the leadership team acknowledged the deployment of staff needed further consideration.

People and their relatives gave us mixed feedback about the home and how clean it was. People gave us positive feedback about the laundry facilities. Comments included, “The laundry is very good, you put your clothes out and they come back all washed within a day or two, sometimes the next day,” and “The laundry lady here is very nice.” One relative told us “I think the home has a lovely vibe, there are no smells, and everything is clean and well looked after.” However, other relatives told us improvements were required with the hygiene levels of the building. Comments included “The cleaning is not very good, and things are left cluttered” and “The main negative concern I would have, is the level of cleanliness. Often the place is not very tidy and there are sweet papers and food left about. Sometimes the toothbrush is still in the sink and toiletries are not put away properly.” Other comments from relatives referred to dirt in their relatives’ room, with one having to ask to get the room cleaned properly.

Staff told us there were cleanliness concerns and gave us example of how bodily fluids in people’s rooms had not always been cleaned properly. Staff who provided feedback told us they were aware of their role in preventing and controlling infections. They were aware of what personal protective equipment (PPE) to use when supporting people.

People were put at risk of harm due to poor infection control and prevention practices. On our first day of visiting the home, we observed areas which required additional cleaning. We made the registered manager aware of our concerns for immediate remedial action to be taken. We found toilet brushes full of soiled toilet paper, we found food items exposed to the air which should have been in containers. We found hot water boilers with limescale stains and fridges and freezers in communal areas were poorly cleaned and contained out of date products which could have caused harm to people. Although the registered manager responded to our concerns, we found ongoing concerns on our second day. We found people’s rooms were unclean. One person’s room had brown stains covering their duvet cover, and stains of liquid on top of their radiator.We noticed these issues were not addressed by the houeskeeping staff when they cleaned the room. We found staff did not routinely observe good hand hygiene, we observed one member of staff taking a meal to a person, stopped on the way to enter a bathroom and then supported another member of staff open a sluice room door with the meal still in their hand. We found items of personal protective equipment (PPE) were disposed of in domestic bins. We observed food was stored in furniture which had porous surfaces. We found the surfaces to be unclean. For instance, honey was found on surface of a cupboard. People were at an increased risk of infection due to poor hygiene.

An Infection Protection and Control audit was conducted in December 2023. The assessment concluded with a score of 100% compliance and an outstanding rating awarded by the registered manager. However, this was not in line with our findings. Whilst most staff had received training in infection, prevention, and control (IPC) there was evidence this training was not being applied in the service.

People were supported to receive support with their medicines in a way that met their individual needs and preferences. Staff were polite, gained consent and administered medicines safely. Guidance in the form of PRN protocols were in place for medicines prescribed on a when required basis to be administered consistently. Medicines were reviewed regularly and not used to control people’s behaviour. People received their medicines in a kind and person-centred way. Staff were knowledgeable about the care needs of people living at the service. PRN protocols were in place where people were prescribed medicines which are used for conditions such as pain and constipation to be administered ‘when required’ (PRN). People’s preferences about how they wanted their medicines administered was recorded on the electronic medicines administration record (e-MAR). People at the service were supported to self-administer medicines where possible. The clinical pharmacist and GPs from the local GP practice carried out medicine reviews annually. People’s behaviour was not controlled by the inappropriate use of medicines.

Staff were trained to ensure that medicines were used safely and effectively. Staff told us they were given a good amount of time to shadow and learn before being asked to do medicines independently. Regular audits were carried out by staff to identify gaps and improve medicines management. A recent external audit was also carried out by the pharmacist from the local community pharmacy which provided assurance, medicines management at the home was safe. Staff told us there was a good training and induction process for medicines management. Staff were given time to shadow and learn how to administer medicines before being able to sign off as competent. Additional training was available for staff where needed. Training in medicines administration was refreshed annually. The service completed both internal and external audits.

There were processes and policies in place to ensure that people received medicines safely. Medicines were stored securely and at appropriate temperatures. This was supported by an electronic medicines administration record (e-MAR). However, the equipment used for e-MAR was not always fit for purpose. There had been medicine-related incidents at the home which were being investigated by the management. The home management had arranged for additional training to support staff handle medicines safely. The service used an electronic medicines administration record (e-MAR) to help manage medicines safely. The system allowed the recording of regular and ‘when required’ (PRN) medicines. It also included reminders that supported staff to give medicines in a timely way in line with medicines instructions, especially time-sensitive medicines. However, the equipment i.e. laptops used by staff did not hold an adequate electric charge, as a result, the staff had to plug the laptop into electric sockets while giving medicines. This caused a delay in the timely completion of the medicines round. 3 out of 10 e-MARs we reviewed did not have medicines-related allergies recorded on them. PRN protocols (documents to support staff to know how and when to administer a PRN medicine safely were in place and accessible at the point of administration. One person we reviewed was assessed and supported by staff to self-administer their medicines. Medicine care plans and assessments were in place to support people with their health needs. Medicines including controlled drugs were stored securely and at appropriate temperature. There was a process in place to report and investigate medicine errors and incidents. There had been recent incidents related to prescribed medicines which were being investigated by the management.