CQC report explained · a nursing home
What the CQC found at Primrose Lodge Care 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, January 2024
Primrose Lodge Care Home is rated Requires Improvement; inspectors found unsafe medicines management, staffing shortfalls and weak oversight, despite kind care and improvements in infection control.
This was an unannounced focused inspection on 25 April and 4 May 2023. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care, medicines, staffing and management records.
The home was not always safe. Medicines records did not always show that medicines were given as prescribed. There were also concerns about medicine stock counts, allergies, medicated patches and guidance for medicines given when needed.
Staffing systems did not accurately reflect people's needs. People, relatives, staff and professionals said there were not always enough staff for person-centred care. The home used agency staff, and some agency staff were seen as less skilled than permanent staff.
The overall rating remains Requires Improvement. Safe, Effective and Well-led were also rated Requires Improvement. Caring and Responsive were not examined in this focused inspection, so the overall rating used ratings from the previous inspection.
Infection control
Inspectors found improvements since the last inspection. The home was clean, and staff used protective equipment appropriately.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt safe
Safeguarding systems were in place, and people and relatives said people felt safe.
“People told us they felt safe which was confirmed by relatives.” from the report
Staff training
The home had put a system in place for staff training and support. Inspectors found enough improvement for the previous staffing-related breach about training and support to end.
“A system was in place to ensure staff were supported and trained.” from the report
Health professional links
Staff worked with health and social care professionals. Regular reviews and multi-disciplinary meetings supported people's health and wellbeing.
“Staff worked in partnership with health and social care professionals.” from the report
Kind staff
People and relatives described staff as caring and said they treated people well.
“People and relatives spoke positively about the caring nature of staff.” from the report
Medicines records
seriousRecords did not always prove that medicines were administered as prescribed. Inspectors found shortfalls in stock counts, allergy records, medicated patches and guidance for medicines given when needed.
“The failure to ensure medicines were managed safely was a breach of Regulation 12 (Safe care and treatment)” from the report
Staffing levels
seriousThe staffing and dependency tools did not accurately reflect people's needs or all the work staff had to do. This meant care could become task-focused rather than centred on each person.
“People, relatives, staff and professionals told us that there was not always enough staff to provide person centred care.” from the report
Weak quality oversight
seriousThe provider had not made enough improvement to its systems for monitoring quality, medicines and staffing. This was the third consecutive inspection where medicines management and good governance regulations were breached.
“The failure to ensure an effective quality monitoring system was in place was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008” from the report
Mealtimes and food choice
needs fixingMealtimes were sometimes task-focused. Inspectors found no evidence that people had been consulted about the choice of halal meat served, apart from pork.
“There was no evidence this had been discussed with people or a choice provided.” from the report
Dementia-friendly surroundings
needs fixingThe décor did not fully meet the needs of people living with dementia. There was limited signage to help people find their way around.
“The décor of the home did not fully meet the needs of people living with dementia.” from the report
Rating not displayed online
minorThe provider was not displaying its CQC performance rating on its website, as legally required.
“The provider had not ensured they were displaying their CQC rating on their website in line with legal requirements.” from the report
- 01What checks now confirm that every medicine is given as prescribed, including stock counts, allergies, medicated patches and medicines given when needed?
- 02How do you calculate the number of staff needed on each shift, particularly for people who may show distressed behaviour?
- 03How many permanent and agency staff are usually on duty, and how do you check agency staff have the right skills?
- 04What changes have been made to make mealtimes more person-centred and to offer people meaningful food choices?
- 05What has changed in the quality monitoring system since the warning notices, and how will you show that improvements are lasting?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the overall rating used ratings from the previous inspection for those areas. This explanation was written from the published report of 9 January 2024 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, January 2023
Primrose Lodge Care Home is rated Requires Improvement; inspectors found ongoing risks with infection control, medicines, staffing and management oversight.
Inspectors made an unannounced visit over two days. They spoke with people, relatives and staff, and checked care plans, medicines records, training information and management checks.
People were not always kept safe. Infection control records were incomplete, staff did not always follow PPE guidance, and topical medicines were not consistently recorded. People, relatives and staff also reported times when there were not enough staff.
Care plans and risk checks were generally detailed. Consent arrangements had improved, and people were supported to contact family and health professionals. However, staff support, training records, fluid charts and management checks were not consistent.
The overall rating remains Requires Improvement. This is the second inspection with this rating. The home had made some improvements, but it remained in breach of regulations covering safe care, staffing and management oversight.
Care planning and risk checks
Care plans were detailed and risks such as falls, weight loss and skin problems were reviewed regularly.
“People's care records showed staff reviewed risk areas such as skin integrity, weight loss and risk of falls on a regular basis.” from the report
Improved consent practice
The home had improved how it assessed capacity and recorded best-interest decisions for sensor mats and alarms.
“Where sensor mats or alarms were in place then a best interests decision had been taken to ensure it was right for the individual.” from the report
Family contact
Systems allowed regular visits, and relatives said they felt welcomed and supported.
“Relatives told us they felt welcomed and supported at the home.” from the report
Healthcare support
People were supported to maintain their health, with care records showing contact with health and social care professionals.
“Care records demonstrated professionals visited the home frequently and staff contacted health and social care professionals for advice and support.” from the report
Infection control
seriousCleaning records were incomplete during a Norovirus outbreak. Staff did not always follow the home's infection control and PPE procedures.
“Cleaning records during this high-risk period were incomplete and did not demonstrate that appropriate infection control processes had been followed.” from the report
Topical medicines
seriousRecords for creams and lotions had significant gaps, including months with no entries. The report says this placed people at risk.
“Topical medicine records contained significant gaps in recording.” from the report
Staffing levels
seriousPeople, relatives and staff reported delays and times when there were not enough staff. Agency staff were used, but checks of their skills and qualifications were not always timely.
“They are short of staff. Sometimes there are no staff in the lounge to stop people from standing up and falling.” from the report
Staff support and training
needs fixingSupervision and appraisals were not consistent. Training records did not clearly show what each member of staff had completed, and some practical training levels were low.
“Records showed no annual appraisals had been undertaken since January 2022.” from the report
Management oversight
seriousManagers knew about gaps in infection, fluid and medicines records but did not consistently make sure they were corrected.
“Management reviews highlighted gaps in records for infection control and fluid intake. However, there was no evidence that action had been taken to address these shortfalls.” from the report
Fluid records
needs fixingFluid charts were often incomplete, with only around half the days recorded in some monthly records. The provider was asked to review this system.
“Monthly records were not well completed, often with only half the days having fluid levels recorded.” from the report
- 01What has changed since the inspection to ensure there are enough care staff on every shift?
- 02How do you check agency staff skills and qualifications before they start work?
- 03How are topical creams and lotions recorded now, including when a person applies their own cream?
- 04How do you check that cleaning and PPE procedures are followed during an infection outbreak?
- 05How are fluid charts checked and acted on when a person does not reach their target?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the other ratings carried over from the previous inspection. This explanation was written from the published report of 18 January 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 Lodge Care Home
7 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- April 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2020
Registered with the Care Quality Commission on 13 May 2020.
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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