CQC report explained · a nursing home
What the CQC found at Primrose House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and risks such as falls, malnutrition, diabetes and pressure sores were assessed. Medicines, staffing, recruitment, infection control, fire safety and maintenance arrangements were found to be suitable.
- Effective?
- Good
- People's needs and choices were assessed, and staff had relevant training and support. The home worked with healthcare professionals and met people's dietary and health needs.
- Caring?
- Good
- Staff treated people with respect and dignity and involved people and relatives in care decisions. People were supported to remain independent and follow their cultural and religious preferences.
- Responsive?
- Good
- Care plans were personalised and staff knew people's needs. Activities were provided, but the home did not have a full-time activities organiser at the time of the inspection.
- Well-led?
- Good
- The home had a management team, regular staff support and quality checks. People, relatives and care professionals said the home was well managed and communication was good.
What inspectors found, April 2020
Primrose House Nursing Home was rated Good overall; inspectors found safe, kind and personalised care, with activities staff cover being the main minor gap.
This was an unannounced inspection on 18 and 20 February 2020. One inspector and an Expert by Experience spoke with six people, four relatives, staff and care professionals. They also reviewed care records, staff files, medicines information, maintenance records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people felt safe, received their medicines, and had their health, dietary and personal care needs met.
Staff were described as respectful, knowledgeable and supportive. The home was clean, risks were assessed, and there were systems for safeguarding, fire safety, complaints and quality monitoring.
The home did not have a full-time activities organiser at the time of the inspection. An appointment had been made, and care staff and the quality assurance manager were organising activities in the meantime. The previous inspection, published in September 2017, was also rated Good.
Safe medicines
People received their prescribed medicines, and inspectors found no unexplained gaps in the medicines records they checked. Medicines were stored securely and audited.
“Medicines administration records (MAR) examined had no unexplained gaps.” from the report
Respectful care
People and relatives spoke positively about how staff treated them. Inspectors also observed friendly and respectful interactions during both inspection days.
“On both days of the inspection, we observed positive interaction between people and staff.” from the report
Personalised support
Care records included people's routines, dietary needs, cultural and religious observances. Staff knew how to support people's individual needs.
“Records contained details of people's needs, their daily routines, dietary, cultural, and religious observances.” from the report
Good healthcare support
The home arranged support from healthcare professionals when needed and followed their guidance. Inspectors found suitable arrangements for health needs including diabetes and pressure sores.
“One healthcare professional told us that staff communicated well and followed their professional guidance when caring for people.” from the report
Good management
The home used audits, checks, meetings and feedback to monitor care. Staff said managers were supportive and approachable.
“The service had a quality assurance system with a quality assurance manager overseeing it.” from the report
Activities staffing
minorThere was no full-time activities organiser during the inspection. An appointment had been made, while care staff and the quality assurance manager organised activities temporarily.
“We however, noted that the home did not currently have a full time activities organiser an appointment had been made.” from the report
- 01Has the full-time activities organiser now been appointed, and what activities are available each week?
- 02How will you assess and monitor activities for someone with dementia or limited mobility?
- 03How are diabetes, pressure sores and other health risks monitored and reviewed?
- 04How often will my relative and our family be involved in reviewing the care plan?
- 05How can we raise a concern, and how will the home record and respond to it?
This was an unannounced comprehensive inspection covering the premises and care, with ratings given for all five areas; the previous inspection was also rated Good. This explanation was written from the published report of 15 April 2020 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 2017
Rated Good; inspectors found safe, respectful care, but some people were unhappy with the meals.
This was an unannounced inspection on 27 July 2017. One inspector visited the home, spoke with people, relatives, staff and health and social care professionals, and checked care records, staff records, medicines, the building and management checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable arrangements for safeguarding, risks, medicines, staffing, cleanliness and fire safety. People's health needs were monitored, and staff had training and support.
People were treated with respect and had care plans, activities and opportunities to give their views. Some people were not fully satisfied with the meals, including the availability of fresh fruit and vegetables. The inspectors made a recommendation for the home to review meals regularly with people and their representatives.
Safe care
Inspectors found good arrangements for safeguarding, risk management, medicines, cleanliness and emergencies. Staff knew how to recognise and report abuse.
“There were suitable arrangements to protect people from harm and abuse and care workers demonstrated an understanding of how to recognise different forms of abuse and how to report these.” from the report
Respect and privacy
People were treated with dignity. Staff knocked before entering bedrooms and protected privacy during personal care.
“We saw care workers knocked on people's bedroom doors and waited for the person to respond before entering.” from the report
Activities and independence
The home offered regular social and therapeutic activities, including exercise, arts and crafts, gardening and outings. People could also take part in suitable household tasks.
“The home had a varied and regular programme of activities to ensure that people received adequate social and therapeutic stimulation.” from the report
Listening and complaints
People and relatives had meetings and other opportunities to share their views. The two complaints recorded in 2017 had been answered promptly.
“Complaints made had been carefully recorded and promptly responded to.” from the report
Management checks
Managers carried out regular checks on care records, medicines and maintenance. Staff said communication was good and people expressed confidence in management.
“Comprehensive audits and regular checks of the service had been carried out by the registered manager and senior managers of the company.” from the report
Meal choices
needs fixingSome people were not fully satisfied with the meals. Inspectors found no fresh fruit or vegetables in the kitchen on the inspection day apart from potatoes, although the home said these had been ordered.
“However, as some people were dissatisfied with the meals provided, we have made a recommendation.” from the report
Personal presentation
minorOne relative said their relative was not wearing their hearing aid and their hair had not been combed. The manager said this would be done in future.
“One relative informed us that their relative did not have their hearing aid on and their relative's hair was not combed.” from the report
Staffing at busy times
minorOne person felt more care workers were needed at certain times of day. The home said it would add a staff member from 8am to 8pm to support prompt care.
“The person who stated there was inadequate staffing stated that there was a need for more care workers at certain times of the day.” from the report
- 01How do you now check that meals match each person's preferences, including fresh fruit, vegetables and vegetarian choices?
- 02What staffing is in place at the busiest times of day, and was the planned 8am to 8pm additional staff member introduced?
- 03How do you check that people have their hearing aids, grooming and other personal care completed as they prefer?
- 04How do you support residents who may find it difficult to communicate in English?
- 05How are mental capacity assessments and Deprivation of Liberty Safeguards authorisations reviewed when people's circumstances change?
This was an unannounced comprehensive inspection covering all five ratings; an earlier focused inspection in January 2017 had found that a previous mental capacity and restriction-related legal shortfall had been put right. This explanation was written from the published report of 22 September 2017 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 Nursing Home
4 rated inspections over 5 years: the service has held its Good rating throughout.
- April 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodstayed GoodEffective: Good
- August 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Registered with the Care Quality Commission on 29 August 2014.
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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