CQC report explained · a residential care home
What the CQC found at Primrose Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, appropriate risk management and safe medicines processes. Infection prevention and control arrangements were also judged effective during a COVID-19 outbreak.
- Effective?
- Good
- People's needs and choices were assessed, staff received training and support, and people were helped with food, drink and healthcare. A minority of mental capacity assessments covered more than one decision and needed review.
- Caring?
- Good
- The report does not give a separate Caring rating. Inspectors could not speak with residents because they were isolating, but relatives gave very positive feedback about the care.
- Responsive?
- Good
- The report does not give a separate Responsive rating. It says care plans included people's support needs, choices and lifestyle preferences.
- Well-led?
- Good
- Inspectors found approachable management, good communication and effective quality checks. Feedback from relatives and staff was very positive.
What inspectors found, July 2022
Primrose Care Home was rated Good; inspectors found safe, effective and well-led care, with a small issue in some mental capacity assessments.
Inspectors visited on 25 February and 18 March 2022 during a COVID-19 outbreak. People were isolating in their rooms, so inspectors could not speak with them. They spoke with six relatives and received feedback from 12 staff, as well as reviewing care, medicine, recruitment and management records.
The home had good infection control, enough staff and safe recruitment. Medicines, risk assessments and incident reviews were managed safely. Staff were trained and supported, and relatives spoke very positively about the care and management.
The overall rating was Good. Safe improved from Requires Improvement at the previous inspection, while Effective and Well-led remained Good. Some mental capacity assessments covered more than one decision, and the manager agreed to review these.
Infection control
The home had effective arrangements for preventing and managing infection during the COVID-19 outbreak. Visitors were screened and relatives said staff wore protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs and safe recruitment checks were completed for new staff.
“There were sufficient staff deployed to meet people's needs.” from the report
Medicines
Medicine records were accurate and showed that people received their medicines on time. The manager checked the records and acted on issues.
“Medicines were managed safely. Staff kept accurate records to show which medicines people were given.” from the report
Management and improvement
Management was described as approachable and supportive. Quality checks were used to identify improvements and create action plans.
“The provider had effective quality assurance systems which successfully identified areas for improvement and learning.” from the report
Mental capacity records
needs fixingSome mental capacity assessments covered more than one decision, which was not in line with the Mental Capacity Act. The manager agreed to review these decisions.
“A minority of MCA assessments covered more than one decision, which was not in line with the Act.” from the report
- 01Have all the mental capacity assessments covering more than one decision now been reviewed and corrected?
- 02How will you maintain infection control and visiting arrangements during any future outbreak?
- 03How do you check that staffing levels remain enough for people's changing needs?
- 04How are people's individual dementia, lifestyle, cultural and religious needs reflected in their care plans?
- 05What improvements have resulted from the home's quality checks and action plans since this inspection?
This began as a targeted inspection of infection prevention and control, then widened to a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not separately rated. This explanation was written from the published report of 1 July 2022 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.
What inspectors found, August 2018
Primrose Care Home was rated Good overall; inspectors found kind, personalised care, but Safe Requires Improvement because medicines records and laundry arrangements had shortcomings.
This was an unannounced inspection on 13 June 2018, followed by an announced visit on 14 June. The provider met inspectors on 20 June at their request. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines records, recruitment files and management records.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. People and relatives described the care positively. Inspectors found a welcoming atmosphere, kind staff, detailed care plans, suitable activities and systems for checking and improving quality.
Safe was rated Requires Improvement. Medicines were mostly managed safely, but some records lacked enough guidance for medicines given when needed, and photographs were missing from medicine records. There were also concerns about separating clean and dirty laundry and dust behind electrical equipment in the laundry. The provider said some issues had been fixed after the inspection.
Kind and respectful care
Inspectors saw staff treat people with patience, kindness and respect. Staff supported people to make choices and remain as independent as possible.
“We saw staff showed people kindness, patience and respect and offered people lots of praise and gentle encouragement.” from the report
Personalised care plans
Care plans included people's preferences, life stories, hobbies and clear instructions for staff. They were reviewed regularly and when needs changed.
“Care plans were personalised, very detailed and included people's choices, preferences, likes and dislikes.” from the report
Staffing and safeguarding
Inspectors found enough staff to meet people's needs promptly. Staff had safeguarding training and understood how to report concerns.
“This meant there were enough staff to meet people's needs promptly.” from the report
Quality improvement
The home used audits and an external review to identify improvements. Inspectors found that actions had been completed or were being addressed.
“This meant audits were effective in identifying and generating improvements within the service.” from the report
Medicines records
needs fixingSome records did not give staff enough guidance about when to give medicines that were prescribed as needed. Photographs were also missing from medicine records, which increased the risk of mistaken identity.
“people's medicine records lacked detailed guidance for staff to follow relating to 'when required' medicines.” from the report
Laundry safety
needs fixingThe laundry had only one entrance, so clean and dirty linen could not be separated effectively. Dust behind electrical equipment created a fire hazard, although the provider said the laundry was deep cleaned after the inspection.
“there was only one entrance to the laundry room which meant clean and dirty linen could not be segregated effectively.” from the report
Best-interest records
needs fixingFor one person receiving covert medicines, the required best-interest documentation was not in place. The provider said it would arrange for the documentation to be completed.
“the appropriate best interest documentation was not in place for the administration of covert medicines” from the report
- 01What changes have been made to the medicines records since the inspection, and how are they checked now?
- 02Do all medicines prescribed as needed have clear written instructions about when they should be given?
- 03Do medicine records now include photographs to reduce the risk of mistaken identity?
- 04What changes have been made to separate clean and dirty laundry safely?
- 05How are best-interest decisions recorded when medicines are given covertly?
This was a comprehensive inspection covering all five key questions; it was the first inspection under the current management, while the previous inspection in February 2017 was under another provider. This explanation was written from the published report of 18 August 2018 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 Primrose Care Home
2 rated inspections over 4 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018GoodSafe: Requires improvementEffective: GoodWell-led: Good
- June 2017
Registered with the Care Quality Commission on 14 June 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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46 live-in carers within about an hour of Sunderland
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,210 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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