CQC report explained · a nursing home
What the CQC found at Primrose House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found better care and staffing, but medicines records and quality checks were still not reliable.
The inspection was unannounced and took place on 12 and 13 July 2023. Inspectors spoke with people living in the home, relatives and staff. They reviewed care plans, medicine records, training records and quality checks.
The home had improved since the previous inspection. Care plans, activities, support with food and drink, staffing and infection control had improved. People and relatives generally spoke positively about the care and management.
There were still important weaknesses. Records for some medicines were not complete, and records about PEG care were not always made by the person who carried out the care. Quality checks did not always find problems or ensure that lessons were learned.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. The home remained in breach of Regulation 17.
Staffing and recruitment
Inspectors found enough staff to meet people's needs and saw that new staff were recruited safely. Use of agency nursing staff had reduced.
“There were sufficient staff on duty to meet people's needs.” from the report
Improved care planning
Care plans had become more personalised and included people's preferences and abilities. They were reviewed when people's needs changed.
“Care plans had been reviewed and updated so they contained more person-centred information.” from the report
Activities and choice
People had more opportunities to take part in activities and maintain relationships. Staff supported people to make everyday choices.
“People had more opportunities to maintain relationships and participate in activities.” from the report
Infection control
The home was clean and inspectors were assured that infection prevention systems were being followed, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Incomplete medicine records
seriousRecords did not always show that topical medicines had been applied as prescribed. The provider started taking action during the inspection, but inspectors could not yet assess whether the changes were working.
“The failure to maintain accurate and contemporaneous medicines records was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
PEG care records
seriousRecords suggested that untrained staff sometimes recorded PEG procedures carried out by trained staff. Records should be completed and signed by the person who provided the care.
“Information provided to us post inspection demonstrated that this was a regular process undertaken in the service whereby untrained members of staff sometimes completed records for trained staff.” from the report
Quality checks did not always work
needs fixingSome health and safety and medicines audits did not identify problems or make sure improvements were sustained. Reviews of incidents, safeguarding concerns and complaints needed more detailed analysis.
“Although there was some reflection evident, this lacked depth and questioning of findings to ensure lessons were learnt.” from the report
Inconsistent staff interactions
needs fixingMany interactions were kind and respectful, but inspectors found this was not consistent throughout the home, particularly in one area.
“However, this was not consistent throughout the home and could be improved.” from the report
Building improvements needed
minorThe home was suitable for people's needs, but inspectors said redecoration and further changes to make it more dementia friendly were still required.
“Although the home was suitable for the needs of the people living there, redecoration was still required and further enhancements to make the home more dementia friendly.” from the report
- 01How are topical medicines recorded now, and how do you check that every application is recorded correctly?
- 02Who is trained to carry out PEG procedures, and how do you ensure that only the person providing the care completes the record?
- 03What changes have been made in response to the continued Regulation 17 breach, and what evidence shows that they are working?
- 04How are staff interactions monitored in the area where inspectors found care was not consistently kind and respectful?
- 05How are you addressing staff changes, redecoration and improvements to make the home more dementia friendly?
This was an unannounced inspection that assessed all five key questions and included infection prevention and control checks; the report compares the findings with the previous inspection published in December 2022. This explanation was written from the published report of 19 December 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, December 2022
Rated Requires Improvement; inspectors found serious safety failures, including unsafe medicines, infection control and fire risks.
This was an unannounced inspection carried out on 26 and 28 September and 10 November 2022. Inspectors reviewed care, medicines, staffing and management records, observed people in communal areas, and spoke with people, relatives and staff.
The overall rating fell from Good to Requires Improvement. Safe was rated Inadequate. Inspectors found unsafe medicines management, poor infection control, unresolved fire risks, incomplete risk assessments and delays when people needed help.
Inspectors also found that people were not always treated with dignity, supported according to their care plans or offered meaningful activities. Records, complaints handling and quality checks were not reliable. A new management team had recently taken over and had started an action plan, but many improvements were still needed.
Staffing numbers assessed
The provider's assessment said staffing levels matched people's assessed dependency needs, although staff were not always placed where they were most needed.
“Staffing levels matched the provider's dependency assessment and permanent staff were recruited safely.” from the report
People's choices assessed
People's needs and choices were assessed and included in care plans. Inspectors found that mental capacity was reviewed regularly.
“People's needs and choices were assessed and incorporated into care plans.” from the report
New management action
The new management team had carried out a detailed audit and identified most of the problems found during the inspection.
“The new senior management team had undertaken a detailed audit of the service which highlighted the majority of the issues identified during the inspection process.” from the report
Partnership working
The new management team was working with infection control specialists, the local authority and health commissioners to address the problems.
“The management team were engaging with external stakeholders to address the areas identified during the inspection process.” from the report
Unsafe medicines
seriousMedicines were not managed safely. Inspectors found an unprescribed cream being used, missing records for PEG care and incomplete records for some medicines given when needed.
“Medicines were not safely managed, and people were at potential risk of harm.” from the report
Infection and cleanliness
seriousStaff did not always use protective equipment correctly. Areas needed deep cleaning and repair, with black mould visible in some corridors and bathrooms.
“We found the home required a deep clean and requested to the registered manager this be actioned immediately.” from the report
Fire and other risks
seriousActions from the fire risk assessment had not been completed. Inspectors found incorrectly fitted fire doors, trip hazards on evacuation routes, items in emergency stairwells and missing fire equipment.
“People were at serious risk of harm, as risks associated with choking, fire, and health and safety had not been fully assessed, mitigated or monitored.” from the report
Dignity and personal care
seriousPeople were seen in unclean clothing and sitting on soiled furniture. Some people waited for help with basic needs, and staff did not always follow care plans.
“People did not receive care in a person-centred, caring and dignified way.” from the report
Few activities
needs fixingPeople were often left watching television or in their rooms, with little social interaction. Staff said there was not enough time to offer activities during normal working hours.
“People did not have access to meaningful activities and were not supported to maintain relationships.” from the report
Weak oversight
seriousAudits and checks had not been completed properly for more than six months. Records were incomplete, and earlier complaints and incidents had not always been investigated or answered.
“The provider did not have effective systems in place to monitor and improve the quality and safety of the service.” from the report
- 01What fire safety actions have been completed, and can you show us the latest fire risk assessment?
- 02How do you now check medicines, including PEG care, creams and medicines given when needed?
- 03How do you make sure staff follow each person's care plan, special diet and moving and handling instructions?
- 04How are staff deployed on each floor so people do not wait for basic help?
- 05What regular activities and visiting arrangements are now available, and how are relatives kept informed?
This was an unannounced inspection of the care home covering all five key questions, including infection prevention and control, and the previous ratings were changed from the last inspection. This explanation was written from the published report of 17 December 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 House
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- October 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- September 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015
Registered with the Care Quality Commission on 4 November 2015.
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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48 live-in carers within about an hour of Gateshead
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Most charge £950 to £1,240 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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