CQC report explained · a nursing home
What the CQC found at Primrose Hill Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found safe staffing and effective care, but medicine systems and oversight were not consistently reliable.
This was an unannounced focused inspection on 2 October 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines, recruitment, training and quality records.
The home had enough staff, safe recruitment, suitable risk assessments and good support with care needs, food, health and consent. Infection control arrangements were also found to be in place.
There were important problems with medicines. Some prescribed medicines were not available for several days, and medicine records were not always completed. The home was no longer in breach of regulations from the previous inspection, but its overall rating remained Requires Improvement.
Risk management
People's risks were assessed and plans were put in place to reduce them. These plans were reviewed monthly or sooner when circumstances changed.
“Risks were assessed, and plans put in place to minimise them. Evaluations were completed every month or sooner if something changed to ensure they remained up to date.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks, including references and DBS checks, were completed.
“People were supported by enough staff to meet their needs safely.” from the report
Effective care
Care plans reflected people's needs and choices. Staff received training and regular updates about changes in people's care.
“People had their needs assessed and care plans put in place to meet their needs and choices.” from the report
Consent and choice
The home had improved its work under the Mental Capacity Act. Staff sought consent and used best-interest decisions where people lacked capacity.
“People were supported in a way which followed the principles of the MCA.” from the report
Improved culture
Staff described improvements in the culture and said the registered manager was supportive and approachable.
“At this inspection we found things had improved.” from the report
Medicines not always available
seriousTwo people did not have access to prescribed medicines for four and five days. Inspectors found no evidence of harm, but this is a safety concern.
“One person did not have access to their prescribed medicine for 4 days and another person did not have access to a newly prescribed medicine for 5 days.” from the report
Medicine records
seriousMedicine administration records were not always completed. A missed signature had not been identified or investigated before the inspection.
“Medicines administration records were not consistently completed.” from the report
Audits did not always lead to timely action
needs fixingMedicine audits and stock checks existed, but they did not always ensure concerns were acted on quickly.
“However, they were not fully effective in ensuring actions were taken in a timely way.” from the report
- 01What has changed to make sure prescribed medicines are available without delay?
- 02How are missed medicine signatures now identified, investigated and followed up?
- 03How often are medicine stock and administration audits reviewed, and who checks that actions are completed promptly?
- 04What evidence can you show that the improvements from the previous inspection have been maintained?
- 05How will you monitor safety while the service remains rated Requires Improvement?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and ratings for questions not inspected were carried over from the previous inspection. This explanation was written from the published report of 14 November 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, May 2023
Primrose Hill Nursing Home was rated Requires Improvement; inspectors found caring staff and safe medicines, but concerns about door gates, consent records and management systems.
This was an unannounced focused inspection on 24 January 2023. Inspectors spoke with people, a relative, staff and managers. They reviewed care records, medicines records, quality checks and recruitment files.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Inspectors found people generally received their medicines, food, healthcare support and planned care safely, but risks linked to door gates had not been assessed.
People's ability to consent had not always been properly recorded. The home also had weak quality checks, and some staff reported poor treatment by senior managers. The provider breached Regulation 11 on consent and Regulation 17 on good governance. The CQC asked for an action plan and will monitor progress.
Medicines
Inspectors found that people received their medicines as prescribed. Records checked for controlled medicines were accurate.
“People received their medicines as prescribed. We observed people being supported to take their medicines and saw staff took time to explain their purpose” from the report
Staff skills
Staff had training, supervision and the knowledge needed for their roles. People said staff understood how to support them.
“An induction and on-going training and support enabled staff to carry out their roles effectively.” from the report
Health support
The home supported people to attend appointments and made referrals to healthcare professionals when needs changed.
“Records reflected referrals had been made to external professionals where changes in people's needs had been identified.” from the report
Learning from incidents
There was evidence that the management team reviewed incidents and shared changes with staff through handovers.
“There was evidence of learning following incidents and events.” from the report
Door gates and consent
seriousDoor gates restricted some people's movement, but the risks and people's capacity to consent had not been properly assessed. Inspectors could not confirm that legal authorisations covered their use.
“Staff had not always considered the use of door gates as restrictive practice restricting a number of people's freedom of movement” from the report
Incomplete capacity records
seriousRecords did not explain why some people were considered unable to make particular decisions, including decisions about covert medicines and door gates.
“People's capacity to make specific decisions had been considered but the rationale as to why someone lacked capacity was not recorded.” from the report
Weak quality checks
seriousAudits were regularly completed but did not identify the problems inspectors found with consent, risk assessments and restraint.
“Audits used to monitor the quality of care people received were not always effective.” from the report
Senior management culture
needs fixingSome staff said senior managers had spoken to them in a way that made them uncomfortable. Some professionals also experienced delays when asking for information about incidents and safeguarding.
“Some staff shared experiences of being spoken to by senior managers in a way which had made them feel uncomfortable.” from the report
- 01Which residents have door gates, and has a separate risk assessment and capacity assessment now been completed for each person?
- 02How do you confirm that any door gate use is the least restrictive option and is covered by the correct legal authorisation?
- 03What changes have been made to the quality audits so they identify consent, restraint and risk-assessment problems?
- 04What action has been taken in response to staff concerns about how senior managers spoke to them?
- 05What progress has been made on the action plan requested by the CQC, and what evidence can you show us?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected during this visit, and the overall rating used the findings from this inspection together with previous ratings. This explanation was written from the published report of 11 May 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 Primrose Hill Nursing Home
3 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- June 2020Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2019
Registered with the Care Quality Commission on 24 January 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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