CQC report explained · a nursing home
What the CQC found at Primrose Hill Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Two of four people checked had not received wound care on the planned day. Risk assessments and care records were not always up to date, although staffing, medicines, recruitment and infection control were generally satisfactory.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management checks did not always identify missing or incomplete records and make sure improvements were sustained. The action plan was not always followed when the registered manager was not working.
What inspectors found, October 2022
Primrose Hill Care Home is rated Requires Improvement; inspectors found caring staff and safe medicines, but gaps in wound care records and management checks.
This was an unannounced focused inspection on 22 August 2022. Two inspectors spoke with four people living at the home and staff, and checked care records, medicine records, recruitment files and management records.
Inspectors found that people generally felt safe. Staffing had recently increased, medicines were usually given as prescribed, infection control was managed safely and staff understood safeguarding responsibilities. However, two of four people checked had not received wound care on the planned day. Records for food and fluids and repositioning were not always completed or reviewed as required.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The rating changed from Good at the last inspection in 2019. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
Staffing
Staffing had recently increased. Inspectors saw enough staff to keep people safe, and staff said they had more time to spend with residents.
“There were sufficient staff to ensure that people were safe.” from the report
Medicines
Medicine records and stock matched, and people said they received their medicines on time. Staff administering medicines had completed training and checks.
“The records and levels of stock tallied to show that people received their medicines as prescribed.” from the report
Infection control
Inspectors were assured that infection prevention measures, including the use of protective equipment and the management of possible outbreaks, were safe.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safeguarding
Staff understood how to recognise and report abuse. People told inspectors they felt safe and that staff knew them well.
“Staff had received training and had a good understanding of the providers safeguarding systems and procedures.” from the report
Planned wound care
seriousTwo of the four people whose records were checked had not received wound care on the planned day. Inspectors said this could put their health at risk.
“For example, the records showed that two people out of the four we checked had not received their wound care on the planned day.” from the report
Incomplete care records
needs fixingFood and fluid records and repositioning records for people at risk of pressure ulcers were not always updated. They were also not reviewed each day as required by the home's action plan.
“Food and fluid intake records and records for repositioning for those at risk of pressure ulcers had not always been updated by staff to demonstrate the care and support given.” from the report
Weak management checks
seriousQuality checks did not consistently find problems or make sure action was taken quickly. The systems were not always followed when the registered manager was away.
“The quality assurance system had not always been effective at identifying areas for improvement and ensuring action was taken in a timely manner.” from the report
Medicine storage records
minorMedicine storage temperatures were not always recorded clearly, and it was not always clear what action had been taken when temperatures were outside the recommended range.
“However, the temperature wasn't always recorded, or the action taken when temperatures were out of range, wasn't always clear.” from the report
- 01How do you now make sure wound care is completed and reassessed on the planned day?
- 02Who checks the food, fluid and repositioning records each day, and what happens when information is missing?
- 03What changes have been made to the action plan since this inspection, and how is progress checked when the registered manager is not working?
- 04How are medicine storage temperatures recorded, and what action is taken when they are outside the recommended range?
- 05Have satisfaction surveys and meetings with residents and relatives now restarted?
This was an unannounced focused inspection of Safe and Well-led only; the other three key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 6 October 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, February 2021
Primrose Hill Care Home was inspected but not rated; inspectors found good infection control arrangements during the COVID-19 pandemic.
This was an unannounced, targeted inspection on 04 February 2021. It looked at infection prevention and control because of the coronavirus pandemic.
Inspectors found checks for visitors, use of personal protective equipment, social distancing and safe admissions. They were assured that testing, cleaning and outbreak arrangements were in place.
The service was inspected but not rated. This was not a full assessment of the home, so the report does not give an overall quality rating or ratings for most of the five areas.
Visitor safety
The home had arrangements for essential visits, including health checks before entry and full protective equipment for staff. Visits were based on people's individual circumstances.
“Checks were in place prior to any visitor entering the building including a temperature check and a health risk assessment.” from the report
Staff protection
Staff used protective equipment and worked in separate groups to help reduce the spread of infection.
“Staff wore full personal protective equipment (PPE) and worked in individual groups and this helped keep people safe.” from the report
Clean environment
Inspectors found that cleaning and governance checks were effective. The premises were reported to be clean, free from smells and uncluttered.
“Audits and governance were effective in ensuring the premises were clean, odour and clutter free.” from the report
Outbreak planning
The home had acted on learning from earlier in the pandemic and had arrangements for positive tests, safe admissions and contaminated waste.
“Swift and effective actions were taken if people or staff tested positive for COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your infection prevention and control arrangements changed since the inspection in February 2021?
- 02What are your current rules for family visits, including visits for people receiving end of life care?
- 03How do you manage testing and isolation when a resident or staff member tests positive?
- 04How do you safely admit someone moving from home or another care setting?
- 05How do you check that cleaning, waste disposal and infection control procedures are being followed?
This was a targeted, unannounced inspection of infection prevention and control during the coronavirus pandemic; it was not a full inspection and the service was not rated. This explanation was written from the published report of 23 February 2021 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 Hill Care Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- August 2019Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- September 2018Requires improvementdown from GoodSafe: Requires improvementWell-led: Good
- January 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- July 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 2011.
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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