CQC report explained · a residential care home
What the CQC found at Primrose Place
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found problems with PPE use, cleaning, disposal of used PPE, fire evacuation plans, food safety records and some medicine storage and recording. The provider made some changes after the inspection.
- Effective?
- Good
- Staff had relevant training and supported people's dietary, healthcare and communication needs. Some staff felt they needed more support to develop their skills, and picture menus had not been developed.
- Caring?
- Good
- People appeared comfortable and relaxed with staff. Staff were seen treating people with kindness, dignity and respect, and people and relatives were involved in care decisions.
- Responsive?
- Good
- People were supported with activities, community visits, relationships and cultural needs. One relative said concerns had not always been dealt with promptly, and some complaints had not been recorded.
- Well-led?
- Requires improvement
- The provider's audits and other checks had not identified or dealt with several safety problems in good time. Inspectors found a breach because governance systems were not effective or robust enough.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found kind and effective care, but safety and management systems were not reliable enough.
Inspectors visited without notice, spoke with people, relatives, staff and health professionals, observed care and reviewed care, medicines, recruitment and management records. Four people were living in the home at the time.
People were treated kindly and with respect. Inspectors rated the home Good for Effective, Caring and Responsive. Staff knew people's choices, supported healthcare access and helped people take part in activities and community visits.
Safety needed improvement. Inspectors found weaknesses in infection control, fire evacuation information, food safety checks and some medicines arrangements. The provider made some changes after the inspection, but these had not yet been tested and embedded.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement because risks were not always managed properly and the provider's checks had failed to identify or fix important problems.
Kind and respectful care
People appeared comfortable with staff and were treated kindly, respectfully and with dignity.
“We saw kind and caring interactions between people and staff.” from the report
Healthcare support
The home worked with health professionals and supported people to attend appointments and receive advice when their needs changed.
“The service is responsive to any changes in service users' needs and they seek timely guidance and support.” from the report
Community activities
People were supported to take part in activities and visit places in the community, including shopping, the gym, swimming and places of worship.
“All people were supported to engage in the community, go shopping, attend the gym, swimming, disco's, singing lessons, go on an annual holiday and to other places of interest.” from the report
Safe recruitment
The provider carried out recruitment checks to help make sure staff were suitable to work in the home.
“This meant checks were carried out to make sure staff were suitable to work in the home.” from the report
Infection control and cleanliness
seriousInspectors found staff not always using PPE correctly, no suitable upstairs disposal arrangements for used PPE, poor cleaning records and dirt and dust in parts of the home. Chopping boards were also too worn to clean effectively.
“We found a build-up of dirt on bedroom doors, carpets and kitchen cupboards and thick dust on light shades.” from the report
Fire evacuation information
seriousFire risk assessments and evacuation plans did not reflect night staffing levels or people's full support needs. Not all staff had taken part in a fire drill.
“Peoples Emergency Evacuation Plans (PEEP's) and the fire risk assessments, did not reflect the decreased staffing arrangements during the night-time period and full support needs of people during this time.” from the report
Medicines records and storage
seriousThe key to the locked medicines cabinet was not stored securely. There were gaps in temperature records, and some creams were not dated or supported by completed body maps.
“This meant untrained staff or visitors could have access to these prescribed medicines.” from the report
Weak management checks
seriousAudits and monitoring had not identified or corrected several problems, including missing food temperature records and infection control risks.
“The provider did not demonstrate effective governance, including quality assurance and auditing systems or processes.” from the report
Activities and independence
needs fixingRelatives and staff felt there could be a more holistic approach to activities, greater independence and longer trips out. Some staff also felt the activity plan was repetitive.
“Relatives and staff told us that although people's needs were met in a timely way there could be a more holistic approach to activities and promoting independence.” from the report
Complaints recording
needs fixingOne relative felt concerns were not always addressed promptly or followed up. Inspectors found those complaints had not been recorded in the complaints records.
“We saw these complaints had not been recorded in their complaint's records but there was evidence that regular communication had been held with the relative.” from the report
- 01What has been done to make sure PPE is available upstairs and used and disposed of safely?
- 02How have the fire risk assessment and emergency evacuation plans been updated for night-time staffing and each person's support needs?
- 03How are medicines cabinet keys, medicine temperatures and opened creams now checked and recorded?
- 04How do managers check that cleaning, food temperatures and other safety checks are completed every day, including at weekends?
- 05How will you provide more varied activities and support greater independence and longer trips out?
This was an unannounced first inspection of the newly registered home, covering all five key questions and infection prevention and control; the previous Good rating was for the service under a different provider in 2019. This explanation was written from the published report of 2 November 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.
What inspectors found, March 2021
Primrose Place was inspected but not rated; inspectors found strong COVID-19 infection control measures.
This was a targeted inspection on 16 March 2021. It looked only at infection prevention and control during the COVID-19 pandemic. The visit was announced the day before.
Inspectors found checks for visitors, regular COVID-19 testing, appropriate use of protective equipment, regular health observations and cleaning schedules. They were assured that the home had measures to prevent and manage infection.
People were supported to keep in touch with important people through video calls, telephone calls and letters. They were also encouraged to exercise, including walks in the local park.
The home was not given an overall quality rating. Safe was recorded as inspected but not rated, and the other four areas were not assessed in this inspection.
Infection checks
Visitors were checked and people and staff had regular COVID-19 testing in line with government guidance.
“Regular testing in line with government guidelines for COVID-19 took place for people and the staff team.” from the report
Protective equipment
Staff were using protective equipment properly. Supplies were available and arrangements were in place for safe removal and disposal.
“Staff were wearing PPE appropriately. There were sufficient supplies of PPE located around the service” from the report
Keeping people connected
People were supported to maintain contact with important people in several ways during the pandemic.
“People were supported to maintain contact with others who were important to them in a variety of ways” from the report
Clean environment
Inspectors found the home clean and saw that regular cleaning schedules were followed.
“The home was kept clean with regular cleaning schedules adhered to.” from the report
Inspectors raised no specific concerns in this report.
- 01What has changed in your infection prevention and control arrangements since the inspection on 16 March 2021?
- 02How do you currently test people living here and staff for infections?
- 03How are visitors checked and supported to visit safely now?
- 04How do people keep in touch with relatives and other important people?
- 05Can you show me the home's latest overall ratings and any more recent inspection reports?
This was a targeted inspection of infection prevention and control during COVID-19; it did not assess Effective, Caring, Responsive or Well-led, and the service was not rated overall. This explanation was written from the published report of 31 March 2021 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 Place
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- April 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2020
Registered with the Care Quality Commission on 28 February 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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