CQC report explained · a residential care home
What the CQC found at Primrose House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found sufficient staff, safe recruitment, suitable risk assessments, safe medicines systems and safeguarding arrangements. The home relied significantly on agency staff and had paused new admissions during recruitment.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found clear management arrangements, extensive quality checks and positive feedback about leadership. The home sought feedback from people, relatives and staff.
What inspectors found, March 2023
Primrose House is rated Good; inspectors found safe, kind care and good leadership, but the home relied heavily on agency staff.
This was an unannounced, focused inspection on 14 March 2023. One inspector spoke with people living there, staff, relatives and a visiting healthcare professional. They also observed care and checked care records, medicines, recruitment files, safety checks and quality records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff on duty, safe recruitment, suitable risk assessments, safe medicines systems and effective safeguarding arrangements. People appeared comfortable with staff, and relatives and healthcare professionals gave positive feedback.
There were some issues to keep under review. The home relied significantly on agency staff and had paused new admissions while recruiting permanent staff. Staff had not recorded opening dates on some liquid medicines, although inspectors found no impact on people. The overall Good rating remained unchanged from the previous inspection.
People felt safe
People appeared comfortable with staff. Relatives and a healthcare professional also gave positive feedback about safety, care and communication.
“Our observations showed people appeared at ease with staff.” from the report
Good risk and safety checks
People had current assessments covering risks such as falls, skin damage and nutrition. The environment and equipment were checked and maintained.
“People had current individual risk assessments. We reviewed examples of risk management in relation to falls, skin breakdown and nutrition.” from the report
Positive leadership
Inspectors found clear roles, regular monitoring and provider-level oversight. Feedback about the manager and the way the home was run was positive.
“There was an extensive range of quality monitoring and governance systems embedded in the service.” from the report
People and families were involved
The home gathered feedback through conversations, meetings and surveys. Changes to food items had been made following feedback.
“Residents and relative meetings were held 4 times a year to capture feedback from people and understand their views of the service.” from the report
Heavy reliance on agency staff
needs fixingThe home had a significant reliance on agency staff to meet staffing levels. It was recruiting permanent staff and had paused new admissions until recruitment improved.
“The service currently had a significant reliance of agency staff to provide care to people.” from the report
Liquid medicine dates
minorSome bottles of liquid medicines did not have their opening dates recorded. The manager said this would be addressed, and inspectors found no impact on people.
“We identified that staff had not recorded the opening date on some bottles of liquid medicines.” from the report
Expired legal authorisation
needs fixingOne authorisation relating to a person's liberty had recently expired. The manager was taking action, but families may want to ask how this was resolved.
“One DoLS had recently expired and the registered manager was taking action as required.” from the report
Community links
minorCommunity links were not in place at the time of the inspection. The manager said this would be reviewed when staffing levels were stable.
“Community links currently were not currently in place; however, the registered manager told us this would be reviewed when staffing levels at the service was stable.” from the report
- 01How has permanent recruitment progressed, and how much are you still relying on agency staff?
- 02Has the pause on new admissions been lifted, and what staffing level was needed before lifting it?
- 03How do you now make sure every liquid medicine bottle has its opening date recorded and checked?
- 04What action was taken after the recently expired DoLS authorisation, and how are current authorisations monitored?
- 05What plans are there to develop community links once staffing levels are stable?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection published on 17 December 2018. This explanation was written from the published report of 28 March 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, February 2021
Primrose House was inspected but not rated; inspectors were assured about infection prevention and control measures.
This was an unannounced, targeted inspection on 29 January 2021. It checked how the home was preventing and controlling coronavirus infections.
Inspectors found that staff used the right protective equipment and had enough supplies. They were also assured about testing, vaccinations, cleaning, visiting arrangements, social distancing and plans for a possible outbreak.
The home was inspected but not rated. This means the visit did not give an overall quality rating or a full rating across all five areas of care.
Protective equipment
Staff were seen wearing protective equipment throughout the building and the inspection. They said supplies had not run low.
“Staff were observed wearing PPE throughout the building and throughout the inspection.” from the report
Infection training and planning
Staff had training about infection control and coronavirus. The home also had a plan for dealing with an outbreak.
“Staff had training and support to understand the fundamentals of infection control and Covid 19.” from the report
Testing and vaccination
Testing for people living in the home and staff was working well. A vaccination programme had been completed for people and staff.
“Staff testing was working well, and the service had completed a vaccination programme for people and staff.” from the report
Cleaning
Cleaning had been increased, including for frequently touched surfaces. Extra cleaning cover was in place across the day and evening.
“Cleaning schedules had been increased to ensure high touch points were being cleaned.” from the report
Inspectors raised no specific concerns in this report.
- 01What visiting arrangements are currently available, and have face-to-face visits restarted?
- 02How will you support contact with family if visits have to be paused again?
- 03How often are staff and residents tested for coronavirus now?
- 04What protective equipment and cleaning arrangements are currently in place?
- 05What is the current plan if there is an infection outbreak?
This was a targeted, unannounced inspection of infection prevention and control during the coronavirus pandemic; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 18 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 House
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2016
Registered with the Care Quality Commission on 24 October 2016.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
17 live-in carers within about an hour of Devon
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 £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
“She is such a warm and gentle person while being professional and competent at the same time.”
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.