CQC report explained · a nursing home
What the CQC found at Primrose Court Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some short-term medicines, topical creams and bowel monitoring records were not always managed correctly. Risk records and plans for managing distress and agitation also needed further development.
- Effective?
- Good
- People received suitable care, health support and dietary support. However, inspectors recommended improving the mealtime experience for people living with dementia.
- Caring?
- Good
- Staff were kind, compassionate and respectful. People were involved in decisions, supported to remain independent and helped to keep in touch with people important to them.
- Responsive?
- Good
- Care was personalised and people had access to activities, trips and transport. Care records needed further improvement, and inspectors recommended more advice and training for end of life care.
- Well-led?
- Good
- Leadership and quality checks had improved, and people, relatives and staff were asked for feedback. Inspectors said some quality checks still needed to identify all problems, including medicine issues.
What inspectors found, July 2023
Rated Good overall, but inspectors found medicines and risk management were not always safe.
This was an unannounced follow-up inspection after serious concerns at the previous inspection. The inspection activity ran from 13 June to 21 June 2023, with a visit to the home on 13 June. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicine records, staff records and service documents.
The overall rating improved from Requires Improvement to Good. Effective, Caring, Responsive and Well-led were all rated Good. Safe was rated Requires Improvement because some medicines were not given as prescribed, risk records needed more detail, and staff needed more support to manage distress and agitation.
People said they felt safe and were happy with the home. Inspectors found enough staff, kind care, better activities, improved leadership and a suitable environment. They also recommended further improvements to mealtimes for people living with dementia, end of life care, care records and medicine systems.
The home was no longer in breach of regulations at this inspection. It had made significant improvements since the previous inspection, when it had breaches and two warning notices.
Enough staff
Inspectors found enough experienced staff on duty. Staff had time to provide care and take part in meaningful discussions and activities.
“There were enough experienced staff on duty at all times to support people.” from the report
Kind and respectful care
Staff knew people well and treated them with kindness, dignity and respect. People were supported to make choices and keep their independence.
“People were supported by kind and compassionate staff who knew them and their backgrounds well.” from the report
Activities and relationships
People could take part in activities in the home and community. Three activities co-ordinators provided activities across seven days, with access to the home's car and bus.
“Three activities co-ordinators were employed providing activities over 7 days.” from the report
Improved leadership
Inspectors found clear improvements in management, quality checks and staff teamwork since the last inspection. People and relatives had confidence in the management team.
“The provider had made significant improvements to the service since the last inspection.” from the report
Medicines were not always managed correctly
seriousSome people did not receive antibiotics or topical creams as prescribed. Records for bowel monitoring were not always current or accurate.
“Some people did not receive their topical creams as prescribed and further work was needed to ensure people who required bowel monitoring as part of their medicines had up to date and accurate records.” from the report
Risk and distress records need improvement
seriousRisk records were not always individualised enough. Staff needed more support to put their training into practice, particularly when managing distress and agitation.
“Records to support risk management had improved but required continued development to ensure they were individualised and supported staff to manage the risks associated with people's health and well-being.” from the report
Dementia mealtimes
needs fixingInspectors found staff could be task-focused and communication during meals was limited. The provider was asked to review the mealtime experience for people living with dementia.
“We found staff were task orientated and communication was minimal.” from the report
Care records and end of life training
needs fixingCare records did not always give a complete picture of people's routines and needs. Inspectors also recommended more advice and training for staff providing end of life care.
“Care records needed continued improvements to ensure they gave a holistic view of the person and their routines to enable staff to fully support people.” from the report
- 01What checks now make sure antibiotics and topical creams are given exactly as prescribed?
- 02How will you improve the records for bowel monitoring and individual risks?
- 03What extra support do staff receive to manage distress and agitation in line with national guidance?
- 04What changes have been made to mealtimes for people living with dementia?
- 05What training and support do staff receive for end of life care?
This was an unannounced follow-up inspection covering all five key questions, after the previous inspection found breaches and required improvements. This explanation was written from the published report of 4 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.
What inspectors found, September 2022
Requires Improvement overall; inspectors rated safety Inadequate and found unsafe medicines, weak risk management, poor records and restrictions on people's choices.
This was an unannounced inspection. Inspectors visited on 28 July and 4 August 2022, with inspection activity from 28 July to 9 August. They spoke with people, relatives and staff, and reviewed care plans, medicines records, staff files and management records.
The most serious problems were with medicines, risk assessments, fire safety, infection control and record keeping. The home did not always give people personalised care, protect their dignity, provide activities or meet communication needs. Inspectors also found damaged and poorly maintained areas of the building.
There were some positives. The home had enough staff, recruitment checks were completed, safeguarding concerns were handled properly, and people had enough food and drink. Staff said they felt supported, but the systems used by managers had not found or fixed all the problems.
The overall rating was Requires Improvement. Safe was rated Inadequate. Effective, Caring, Responsive and Well-led were all rated Requires Improvement. The home remained in breach of regulations after its previous Requires Improvement rating in September 2020.
Enough staff
Inspectors found enough staff to meet people's care needs, including one-to-one support.
“The service had enough staff, including for one-to-one support to meet people's care needs.” from the report
Safe recruitment
Recruitment records contained the required checks, including checks to assess staff suitability.
“Staff were recruited safely. Staff underwent a robust recruitment process.” from the report
Safeguarding response
Safeguarding concerns were escalated and investigated appropriately. Staff understood how to report concerns.
“Safeguarding concerns were escalated appropriately, and staff had a good understanding of how to report any concerns.” from the report
Food and drink
People were given enough food and drink, with alternatives available when they did not want the planned meal.
“People were given enough to eat and drink and there were choices available if what was on the menu was not to their liking.” from the report
Staff support
Staff reported good morale and felt supported by the management team.
“Staff felt well supported and morale amongst staff was good.” from the report
Risks and fire safety
seriousRisk assessments were missing or incomplete. Fire drills had involved only five of 53 staff, so inspectors could not be assured that staff knew what to do in an emergency.
“We were not assured staff knew how to respond in an emergency and service users were exposed to risk of harm.” from the report
Infection control and cleanliness
seriousSome areas were dirty or damaged in ways that made cleaning difficult. Staff did not always use protective equipment correctly, increasing the risk of infection and cross-contamination.
“Poor IPC practices placed people at increased risk of infection and cross contamination.” from the report
Restrictions on freedom
seriousBlanket restrictions were used rather than making decisions around each person's needs and legal protections. For example, people were not allowed to go out after 8pm.
“We found that blanket restrictions on people's freedoms were in place.” from the report
Very few activities
needs fixingPeople told inspectors they were bored. The activities planner was blank and most people did not have the chance to join activities during the inspection.
“People told us there was nothing to do. We saw very few activities going on during our visits.” from the report
Dignity and respect
needs fixingInspectors saw examples of care that did not protect privacy or dignity, although they also observed positive and kind interactions.
“Staff did not always treat people with dignity or respect their privacy.” from the report
- 01What changes have been made to medicine storage, staff competency checks, patch records and thickener use since the warning notice?
- 02How many staff have now completed fire drills, and how are you checking that they can respond safely in an emergency?
- 03What individual assessments and legal authorisations are now in place for people who have restrictions on going out or using the kitchen?
- 04What activities are currently available for people with dementia, mental health needs and younger people, and how are their preferences recorded?
- 05How have care plans, incident records and quality audits been improved so that changes in people's needs and risks are identified promptly?
This unannounced inspection considered all five key questions, including care, premises, medicines, infection control, records and management systems. This explanation was written from the published report of 8 September 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.
Every inspection of Primrose Court Nursing Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- July 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2022Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2020Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2019
Registered with the Care Quality Commission on 23 August 2019.
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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