CQC report explained · a residential care home, run by Achieve Together
78 Stubbington Lane
78 Stubbington Lane, Stubbington, Portsmouth Hampshire, PO14 2PE
Rated Good: inspectors found the service performing well and meeting their expectations.
What inspectors found, July 2023
Rated Requires Improvement, with an Inadequate safety rating; inspectors found serious problems with risks, medicines, safeguarding and management.
Inspectors visited unannounced on 19, 22 and 25 May 2023. They spoke with people, relatives, staff and a visiting professional. They reviewed care records, medicines, staff files and management records.
They found people were at risk because risk assessments and care plans were incomplete or out of date. Medicines records and instructions were not always correct. Some safeguarding incidents had not been reported, and not all staff had the training needed to support people safely.
People were not always involved in decisions about their care. Some care was task-focused, people were not always treated with dignity, and activities depended on having enough trained staff. The home also had weaknesses in consent, communication, food, repairs and management oversight.
The overall rating means the home was not consistently providing safe, effective, caring, responsive or well-led care. A new manager had started during the inspection and the regional manager began an action plan, but inspectors said improvements still needed to be made.
Infection control
Inspectors were assured that infection prevention arrangements were in place, including safe use of protective equipment and management of infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Access to the community
People were able to have visitors and could take part in community activities when enough appropriately trained staff were available.
“When enough appropriately trained staff were on duty people were supported to go out to places such as the beach, the New Forest, cinema, and bowling.” from the report
Secure records
Care files and confidential information were stored securely and were accessible only to authorised staff when needed.
“Care files and confidential information about people was stored securely and only accessible by authorised staff when needed.” from the report
Action during inspection
The regional manager responded quickly to some concerns raised by inspectors, including making a speech and language therapy referral and updating risk information.
“The regional manager who had been in post for 3 months at the time of the inspection was very responsive to concerns raised throughout the inspection and began to act immediately.” from the report
Risks were not managed
seriousRisk assessments did not always give staff enough guidance. Inspectors saw concerns about choking, health conditions, evacuation arrangements, hazardous cleaning products and food storage.
“The failure to ensure people were provided with safe care and treatment and risks were assessed, monitored, and mitigated was a breach of Regulation 12” from the report
Medicines records were unsafe
seriousSome instructions for medicines did not match prescriptions, some medicines were missing from records, and administration records were not always signed.
“Medicines Administration Records (MAR) charts were not always signed to evidence if medicines had been administered.” from the report
Safeguarding incidents were missed
seriousSome incidents had not been referred to the local authority or notified to CQC. Not all staff had safeguarding training.
“During the inspection we identified a further 3 notifiable incidents which had occurred and had not been referred to safeguarding or notified to CQC.” from the report
Consent and restrictions
seriousThe home did not always follow the Mental Capacity Act. Two people were continuously monitored in their bedrooms, without a clear rationale or evidence that less restrictive options had been considered.
“There was not a clear rationale for this level of monitoring.” from the report
Care was not personalised
needs fixingCare plans were sometimes over a year old, copied from other records or contained incorrect names and information. People and relatives were not consistently involved in planning or reviewing care.
“There was evidence care plans had not been written for individual people.” from the report
Limited activities and outings
needs fixingPeople could not always go out because this depended on having enough trained staff. Relatives said some people were doing very little.
“Where they haven't had staff [person] hasn't been able to go anywhere, they are not getting all the care they previously had.” from the report
- 01What has been done to make sure every person's risk assessment and care plan is current, accurate and followed by staff?
- 02How are medicines now checked, including PRN instructions, medicated creams and signed MAR charts?
- 03How are safeguarding concerns identified, recorded, referred to the local authority and notified to CQC?
- 04What evidence is there that Mental Capacity Act assessments, best-interest decisions and any restrictions are lawful and least restrictive?
- 05How will you ensure there are enough appropriately trained staff for personal care, healthcare needs and regular activities outside the home?
This was an unannounced inspection of the care home covering all five CQC key questions, including infection prevention and control, and it was the first inspection under the current provider. This explanation was written from the published report of 20 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 78 Stubbington Lane
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- December 2020
Registered with the Care Quality Commission on 1 December 2020.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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Other services run by Achieve Together Limited
141 other services on the CQC register. A pattern across a group tells you more than one report.