CQC report explained · a residential care home
What the CQC found at Primrose Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, safe medicines management and risk assessments, but recommended a sink in the laundry room to help with infection control.
- Effective?
- Good
- Care assessments and reviews reflected people's needs, choices and preferences. Staff had the training and support they needed, and people's healthcare, food and drink needs were met.
- Caring?
- Good
- Staff were kind, caring, friendly and attentive. People and relatives said they felt cared for, and inspectors saw staff protecting people's privacy, dignity and independence.
- Responsive?
- Good
- Care was flexible and personalised, and staff knew people's likes, dislikes and histories. People had access to activities, and the home had a complaints procedure.
- Well-led?
- Good
- The home had clear management responsibilities and regular checks on medicines, hygiene, the environment, training and staff performance. People, relatives and healthcare professionals spoke highly of the service.
What inspectors found, September 2019
Primrose Lodge was rated Good; inspectors found safe, kind and personalised care, with one recommendation about infection control.
This was an unannounced inspection on 01 August 2019. Two inspectors spoke with people living at the home, relatives, staff and a healthcare professional. They reviewed care records, medicine records, recruitment checks, training records and quality audits.
The inspectors found that people felt safe and well cared for. Staff were kind, respectful and attentive. There were enough staff, medicines were given safely, risks were assessed and care plans reflected people's needs and preferences.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home was clean and tidy, but inspectors recommended adding a sink in the laundry room to support infection control. The previous overall rating was also Good.
Kind and respectful staff
Inspectors saw staff supporting people with kindness, attention and respect. People and relatives said they felt cared for.
“Our observations showed staff were kind, caring, friendly and attentive.” from the report
Enough staff
The inspectors found sufficient staff to meet people's needs. Staff also had time to sit and talk with people.
“There were sufficient numbers of staff employed to ensure people's needs were met.” from the report
Personalised care
Care plans included people's preferences, abilities and personal, cultural and religious beliefs. Staff knew people well and adapted their support.
“People's preferences were respected, and staff were sensitive and attentive to people's needs.” from the report
Safe medicines
Medicines were stored, administered and disposed of safely. Staff who gave medicines had training and competency checks.
“Medicines were managed safely, and people received their medicines as prescribed.” from the report
Laundry-room sink
minorThere was no sink in the laundry room for soaking soiled garments. Inspectors recommended adding one to support infection control.
“A recommendation was made to add a sink within the room to aid infection control.” from the report
- 01Has the recommended sink been added to the laundry room, and how are soiled garments handled now?
- 02How many staff are usually available on each shift, and how is this matched to residents' needs?
- 03How are care plans reviewed when a person's needs, preferences or health changes?
- 04What activities are available, and how are they matched to each person's interests and communication needs?
- 05How can relatives raise concerns, and how will they be kept informed about the response?
This was an unannounced inspection covering all five key questions, and the ratings in each area remained Good from the previous inspection. This explanation was written from the published report of 27 September 2019 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 2016
Primrose Lodge was rated Good overall; inspectors found kind, safe care, but some records and decision-making processes needed improvement.
Inspectors visited the home without notice on 31 October 2016. They spoke with people living there, relatives, staff and visiting health professionals. They observed care and checked care records, medicines records, staff files and quality checks.
The home supported 15 people, many of whom were living with dementia. Inspectors found enough suitable staff, safe medicines practice, kind care and care plans that reflected people's preferences. People were supported with food, drink, health appointments, activities and maintaining their independence.
There were some shortfalls. Mental capacity assessments did not always deal with one decision at a time. Fluid targets, some pain relief records and explanations about food and drink were not always recorded as clearly as they should have been. Some people were not offered individual activities during the visit.
All five areas were rated Good. This means the inspectors found the service was meeting the relevant standards at the time, although improvements were still needed in the areas identified.
Safe staffing
Inspectors found that staffing levels met people's care needs. Recruitment checks were completed before staff started work.
“We found that the provider had employed suitable numbers of staff to meet people's support requirements.” from the report
Kind and respectful care
Staff treated people with kindness, protected their privacy and dignity, and took time to reassure people who were confused.
“People's dignity and privacy was respected by staff who showed kindness and compassion.” from the report
Personalised care
Care plans recorded people's likes, dislikes and routines. Staff knew people's histories and adapted care to their preferences.
“People's care plans were focused on them as individuals and detailed their preferences and individual support requirements.” from the report
Health and nutrition support
People were offered food and drink they enjoyed and received support with eating. Staff sought specialist advice when needed and referred people to healthcare services.
“Where there were concerns about people's eating and drinking, the registered manager had sought specialist advice.” from the report
Mental capacity records
needs fixingAssessments sometimes grouped several decisions together instead of considering each important decision separately. The provider said it would review them.
“the provider did not always follow the requirements of the Mental Capacity Act 2005.” from the report
Fluid monitoring
needs fixingMonitoring charts did not always state how much fluid each person needed to drink. The manager said this would be added to care records.
“the registered manager had not detailed within their monitoring charts the target amount of drink for each person.” from the report
Pain relief records
needs fixingThe records showed when medicines were given, but the amount of pain relief was not always recorded. The deputy manager said staff would be reminded.
“Where people were offered pain relief, the amount was not recorded.” from the report
Individual activities
minorAlthough people took part in group and interest-based activities, some people were not offered individual activities during the inspection day.
“During the day we found that some people were not offered individual activities.” from the report
- 01What changes have been made so that each mental capacity assessment covers one significant decision at a time?
- 02How are individual fluid targets recorded and checked now?
- 03How do you record the amount of pain relief given, including medicines given when needed?
- 04How are individual activities provided when the activities co-ordinator is away?
- 05Have staff meetings become regular, and how can relatives see what improvements have followed from feedback?
This was an unannounced inspection covering the overall quality of the service and all five CQC questions, with ratings given for Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 7 December 2016 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
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- September 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 9 November 2010.
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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