CQC report explained · a nursing home
What the CQC found at Priory Mews Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some people's risks, including risks linked to epilepsy, diabetes and skin damage, had not been fully assessed. Two people had not received medicines safely or as prescribed, although staffing, recruitment and infection control had improved.
- Effective?
- Good
- Training and supervision had improved, and staff were observed providing safe care. People received better support with eating, healthcare, consent and moving around the home.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Inspectors saw a calmer atmosphere, and people and relatives said staff knew them and understood their needs.
- Responsive?
- Requires improvement
- Activities, complaints handling and opportunities to socialise had improved. However, some care plans did not include enough information about people's lives, preferences, religious needs or end-of-life wishes.
- Well-led?
- Requires improvement
- The manager and staff culture had improved, but audits and action plans were not reliable enough to identify and correct all risks. The home was still in breach of Regulation 17, and there was no registered manager in post during the inspection.
What inspectors found, December 2023
Rated Requires Improvement; care and staffing improved, but medicines, risk records and management checks were still not reliable.
Inspectors visited without notice on 8, 9 and 10 November 2023. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, staff files and management checks.
The home had improved since its previous Inadequate rating. Staff numbers, recruitment, training, cleanliness, activities, healthcare support and the way people were treated had all improved. People and relatives generally said they felt safer and were happy with the care.
However, some risks were not properly assessed. Medicines were not always given safely or as prescribed. Care plans did not always contain enough personal information or guidance. Management audits had not identified all these problems. The home was still breaching Regulations 12 and 17.
The overall rating is Requires Improvement. Safe, responsive and well-led were Requires Improvement, while effective and caring were Good. The home left Special Measures because it was no longer rated Inadequate, but CQC will continue to monitor its progress.
Kind and respectful care
People were treated with dignity and respect. Inspectors saw staff using a caring approach and found a calm, happy atmosphere.
“People were well supported and their privacy and dignity was respected and promoted.” from the report
Improved staffing
Staff numbers had improved, agency use had reduced and recruitment checks were safer. People were more often supported by staff who knew them well.
“The provider ensured there were sufficient numbers of suitable staff.” from the report
Better activities and social contact
People had more chances to join activities, go out and spend time with others. Staff also visited people who stayed in bed or in their rooms.
“People had more opportunities to join in meaningful activities throughout the day as they wished.” from the report
Improved cleanliness
The home was cleaner and infection control practices had improved. Inspectors found no unclean areas and equipment was clean.
“People were protected from the risk of infection as staff were following safe infection prevention and control practices.” from the report
Individual risks not fully assessed
seriousSome people did not have specific risk assessments for epilepsy, diabetes or skin damage. This meant staff might not have had enough guidance to prevent harm.
“The provider failed to assess and monitor the risks to the health and safety of people or do all that was reasonably practicable to mitigate risks.” from the report
Medicines were not always safe
seriousOne person received medicine past its expiry date. Another person was given insulin without extra monitoring when blood sugar was below the recommended range.
“2 people had not received their medicines safely or as prescribed.” from the report
Care plans lacked important detail
needs fixingSome plans did not explain people's history, preferences, cultural or religious needs, or the support needed at the end of life. The provider started work to address this.
“Some people did not have an individual plan in place.” from the report
Management checks missed problems
seriousAudits and action plans were not joined up or followed through consistently. They had not identified some medicine and risk management problems found by inspectors.
“The provider failed to keep accurate records and to operate a robust system to monitor the quality and safety of the service provided.” from the report
- 01What checks now make sure medicines are in date, given as prescribed, and followed by the right monitoring for people with diabetes?
- 02How do you make sure every person has current risk assessments for epilepsy, diabetes, skin damage, falls and other individual risks?
- 03How are care plans being updated to include each person's history, preferences, religious or cultural needs and end-of-life wishes?
- 04How are audits and action plans checked to make sure problems are identified, fixed and followed up across all units?
- 05Is the manager now registered with CQC, and who is legally responsible for the home while registration is being considered?
This was an unannounced inspection covering all five key questions, including the premises and care provided; it followed concerns about safety and checked progress after the previous Inadequate rating and enforcement action. This explanation was written from the published report of 15 December 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 2023
Rated Inadequate and placed in special measures; inspectors found serious shortfalls in safety, staffing, dignity and management.
This was an unannounced inspection on 22 and 23 February 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records. Relatives were also contacted by telephone.
Inspectors found that people were at risk of harm. Risks were not always assessed or managed, medicines were sometimes given or stored unsafely, staffing was not sufficient in some units, and incidents were not always reported or reviewed. Some areas were unclean or unsafe.
Care was not consistently kind, dignified, personal or responsive. Many people were kept in bed without clear reasons, some were left calling for help, and some did not receive enough support with eating, communication or activities. People's legal rights were not always respected.
All five areas were rated Inadequate: Safe, Effective, Caring, Responsive and Well-led. The home is in special measures. The CQC will request an action plan, monitor progress with the local authority and normally re-inspect within six months.
Visitors allowed
People's loved ones and friends could visit whenever they wished, without restrictions.
“People could have visitors at any time without restriction.” from the report
Healthcare referrals
The home did refer people to healthcare professionals, including dieticians, tissue viability nurses and mental health teams.
“People were referred to healthcare professionals to make sure they received the appropriate advice and treatment.” from the report
End of life plans
People had end of life care plans. Some plans recorded wishes such as whether someone wanted to remain at the home or go to a hospice.
“People had end of life care plans in place.” from the report
Some positive interactions
Inspectors saw some kind interactions, and some relatives gave positive feedback about care in certain units.
“We did see some nice interactions between staff and people.” from the report
People at risk of harm
seriousRisks such as choking, falls, distress, catheter care and unsafe surroundings were not always properly assessed or managed.
“People were not protected from harm.” from the report
Unsafe medicines
seriousMedicines were not always given as prescribed. Inspectors also found unsafe crushing of a medicine, poor management of covert medicines and problems with storage and diabetic monitoring.
“People were not always receiving their medicines as prescribed.” from the report
Insufficient staffing
seriousAgency staff covered vacancies, but staff were not always deployed safely or quickly enough. One high falls-risk person's alarm sounded for more than 10 minutes before anyone attended.
“There were not always sufficient staff to meet people's needs.” from the report
Loss of dignity and choice
seriousSome people were left calling out, exposed in bed or without timely personal care. Many people were kept in bed without clear reasons or proper consideration of their consent and rights.
“People were not supported to maintain their privacy and dignity.” from the report
Poor personalised care
needs fixingCare plans lacked important details and were sometimes inaccurate. Some people did not receive enough support with eating, communication, activities or maintaining their mobility.
“Some people did not always receive care that was personal and individual.” from the report
Weak oversight
seriousAudits and monitoring did not identify many of the problems found by inspectors. Complaints, safeguarding concerns and incidents were not consistently recorded or used for learning.
“Completed audits did not pick up the many areas that we found needed serious improvement.” from the report
- 01What immediate action has been taken to make risk assessments accurate, especially for falls, choking, distress, catheters and people being cared for in bed?
- 02How many permanent and agency staff are now working on each unit, and how are you making sure staff know each person's needs?
- 03How are medicines now checked, including diabetic care, covert medicines, medicine times, storage temperatures and medicines that must not be crushed?
- 04How do you make sure people are supported with dignity, personal care, eating, communication, activities and getting out of bed where appropriate?
- 05How will you show that complaints, safeguarding concerns and incidents are recorded, investigated and used to improve care?
This was an unannounced inspection covering all five key questions, including the premises, care and infection prevention measures; it was the first inspection of the new provider. This explanation was written from the published report of 23 August 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Priory Mews Care Home
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- December 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2023Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- January 2021Goodup from Requires improvementSafe: GoodCaring: GoodWell-led: Good
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2022
Registered with the Care Quality Commission on 30 August 2022.
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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39 live-in carers within about an hour of Kent
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 33 can care for a couple. 12 years' experience on average.
“Always on time and with a lovely smile for my mum. Theresa is kind and sensitive to my mum's needs.”
“Irene was a very kind and empathetic carer who knew just the right words to say to put a smile on my face.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.