Archived: Primrose House

Updated 3 August 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 29 June and 13 July 2016 and was unannounced. The inspection was carried out by one adult social care inspector.

Prior to the inspection taking place, information from a variety of sources was gathered and analysed. This included notifications submitted by the provider relating to incidents, accidents, health and safety and safeguarding concerns which affect the health and wellbeing of people.

We contacted the local authority and we received no information of concern.

Information was gathered from a variety of sources throughout the inspection process. We spoke with four staff members at the home. This included the registered manager and three staff who provided direct care.

Not everyone who lived at the home was able to speak with us due to their learning disabilities. We spoke with one person who lived at the home to obtain their views on what it was like to live there. We observed interactions between staff and people to try and understand the experiences of people who lived at the home.

We spoke with two relatives and one friend of a person who visited the home. We also spoke with one professional to see if they were satisfied with the care provided.

To gather information, we looked at a variety of records. This included care plan files relating to two people who lived at the home and recruitment files belonging to four staff members. We viewed other documentation which was relevant to the management of the service including health and safety certification & training records.

We looked around the home in both communal and private areas to assess the environment to ensure it was conducive to meeting the needs of people who lived there.

Updated 3 August 2016

This unannounced inspection took place on 29 June and 13 July 2016.

Primrose House provides personal care up to 6 people with learning and physical disabilities. The home is a single storey, purpose built building. There are disabled facilities and equipment and a sensory room on site. The home is staffed on a 24 hour basis including waking watch carers throughout the night. There were three people who lived at the home on the day of inspection.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was last inspected on 14 and 21 May 2015. At this inspection we found the registered provider was not meeting all the fundamental standards. We identified breaches to Regulation 12, 17 and 18 of the Health and Social Care Act 2014. Suitable arrangements were not in place to ensure medicines were administered in line with current guidance. Paperwork and staff training was not up to date and staff were not suitably supported within their role.

Following the inspection in May 2015, we asked the registered provider to submit an action plan to show what changes they were going to make to become compliant with the appropriate regulations. The registered provider returned the action plan to demonstrate the improvements they intended to make. We used this inspection to look to see if the action plan had been completed and to ensure all fundamental standards were now being met.

At this comprehensive inspection carried out in June and July 2016, we found improvements had been made and the registered provider was now meeting all the required fundamental standards.

Feedback on service provision was positive. People spoke highly about the quality of service.

Improvements had been made to ensure staffing levels met people’s needs. Staffing arrangements were personalised to fit around the needs of the people who lived at the home. People had access to their own transport and were supported to access community activities of their choosing. Staff responded in a timely manner and people did not have to wait to have their needs met.

We observed staff demonstrating patience with people and taking time to sit with them to offer companionship and comfort. People were given time to carry out tasks as a means to promote independence and were not rushed.

Arrangements were in place to protect people from the risk of abuse. Staff had knowledge of safeguarding procedures and were aware of their responsibilities for reporting any concerns.

Suitable recruitment procedures were in place. Staff were checked before employment was secured. The staff turn-over at the home was low and people benefitted from having staff who knew them well.

Improvements has been made to ensure suitable arrangements were in place for managing and administering medicines. Regular audits of medicines were carried out by staff. Protocols for administering as and when medicines were in place and clearly detailed.

Detailed person centred care plans were in place for people who lived at the home. Care plans covered support needs and personal wishes. Plans were reviewed and updated at regular intervals and information was sought from appropriate professionals as and when required. Consent was gained wherever appropriate.

People’s healthcare needs were monitored and referrals were made to health professionals in a timely manner when health needs changed. Documentation regarding health needs of each person was comprehensive and concise.

Systems were in place to monitor and manage risk. Risks were reviewed on a monthly basis and a record was kept to show reviews had taken place.

We saw evidence of multidisciplinary working to ensure people’s dietary needs were addressed and managed in a safe way. Staff were knowledgeable of people’s needs and we observed good practice guidelines being consistently followed.

The registered provider had implemented a range of quality assurance systems to monitor the quality and effectiveness of the service provided. We saw action was taken when audits identified areas for improvement.

Staff were positive about the way the home was managed. Staff described the home as well-led and praised the commitment of the registered manager. Improvements had been made to administrative systems to ensure paperwork was up to date and easily accessible.

Staff had received training in The Mental Capacity Act 2005 and the associated Deprivation of Liberty Standards (DoLS.) We saw evidence these principles were put into practice when delivering care.

Improvements had been made to ensure staff were supported in their role. Staff told us they received supervisions and appraisals as a means for self-development. The registered manager had a training and development plan for all staff. We saw evidence staff were provided with relevant training to enable them to carry out their role.

Staff, people who lived at the home and their relatives all described the home as a good place to live.