CQC report explained · a residential care home
What the CQC found at Primrose Lodge Southbourne
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe. Inspectors found suitable safeguarding, risk assessment, staffing, recruitment, medicines and infection control arrangements.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found visible management, good teamwork, effective quality checks and suitable involvement of people, families and staff.
What inspectors found, July 2023
Rated Good; inspectors found safe, well-managed care, with this visit focused on safety and leadership.
The unannounced inspection took place on 30 June 2023. Inspectors spoke with 12 people using the service, two relatives, a health professional and nine staff. They also reviewed records and the provider's information.
The inspectors found people felt safe and were treated kindly. Staffing met people's needs, recruitment checks were in place, medicines were managed safely and infection control arrangements were effective. Staff understood safeguarding and how to reduce risks.
The home was rated Good overall. Safe and Well-led were both rated Good in this inspection. The other three areas were not inspected, so their previous ratings were used to calculate the overall rating. The overall rating remained Good, as it was at the previous inspection published in August 2018.
People felt safe
People consistently told inspectors they felt safe and had confidence in the staff team.
“People consistently told us they felt safe.” from the report
Safe medicines practice
Staff were trained to give medicines, their competence was checked, and arrangements for medicines given when needed were followed.
“People had their medicines managed safely. Staff had completed medicine administration training and had their competencies regularly checked.” from the report
Effective leadership
Managers were visible and knew people well. Quality checks, surveys and action plans were used to monitor and improve the service.
“Quality assurance systems were multi-layered, linked to regulation and effective at ensuring positive outcomes for people.” from the report
People's views led to changes
Feedback from people and families helped shape improvements, including a secure garden and transport that could accommodate wheelchairs.
“People had expressed they would like a secure, accessible garden to be part of the refurbishment plan, and this had been incorporated into the design” from the report
Inspectors raised no specific concerns in this report.
- 01What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be inspected?
- 02How do you make sure staffing levels remain suitable when people’s care needs change or staff are absent?
- 03How are medicines prescribed for use when needed recorded and reviewed?
- 04How do you prevent and manage infection outbreaks, and what visiting arrangements apply now?
- 05What improvements have come from recent feedback from people and families, and how are these tracked?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 21 July 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, August 2018
Primrose Lodge Southbourne was rated Good; inspectors found kind, personalised care, with some medicine and decision-recording issues addressed during the inspection.
This was an unannounced inspection on 23 July 2018. One inspector and one assistant inspector spoke with nine people, two relatives and five staff. They also reviewed six care records, staff records, audits, accidents and other information.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found that people felt safe, staff knew people well, and care was tailored to people's wishes. People enjoyed the food and had access to activities in the home and local community.
Inspectors found two areas needing attention. Some staff did not understand the risks linked to some medicines, and records of decisions under the Mental Capacity Act were not robust. Senior staff dealt with these issues during the inspection, and CQC made a recommendation about recording these decisions.
Kind, familiar staff
People and relatives spoke very positively about the staff. Inspectors saw a warm atmosphere, and staff could describe what made people happy and how to support them.
“People were cared for by staff who knew them well and cared about them.” from the report
Personalised care and choice
Care plans focused on people's strengths and wishes. People were supported to make decisions, maintain independence and spend their time in ways that mattered to them.
“Care plans focussed on people's strengths, skills and how they could remain in charge of their lives.” from the report
Activities and community
People had access to activities in the home and local community, including trips and holidays. They were involved in social events and planning activities.
“People were supported to carry out activities and spend their time doing things that were meaningful to them.” from the report
Good oversight
The manager and provider representatives monitored the home. Audits and other checks identified improvements, and inspectors saw that action was taken.
“Quality assurance processes were in place and reflected the needs of the home.” from the report
Medicine risk knowledge
needs fixingSome staff did not understand the risks associated with some medicines. Senior staff addressed this as soon as inspectors raised it and shared the learning with the provider's other homes.
“Staff did not understand the risks associated with some medicines and this was addressed as soon as we highlighted it.” from the report
Mental Capacity Act records
needs fixingRecords showing how some decisions had been made under the Mental Capacity Act were not robust. Senior staff completed the missing assessments after the inspection, and CQC recommended further guidance.
“The systems in place around recording decision making within the framework of the Mental Capacity Act 2005 were not robust.” from the report
Oral health plans
minorOral health assessments had been completed, but the findings were not always carried through into people's care plans. Senior staff addressed the documentation.
“We saw that oral health assessments had been undertaken but these did not always translate into care plans.” from the report
- 01What training do staff now receive about the risks linked to people's medicines, and how is their understanding checked?
- 02How do you record Mental Capacity Act assessments and best-interests decisions now?
- 03How are oral health needs recorded in care plans and checked over time?
- 04What activities are available for someone with my relative's interests and communication needs?
- 05Have there been any later CQC inspections or changes to the service since this 2018 report?
This was an unannounced inspection of the overall service and all five CQC questions; the previous overall rating was also Good. This explanation was written from the published report of 30 August 2018 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 Southbourne
3 rated inspections over 8 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Goodstayed GoodSafe: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 2011.
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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