The Care Quality Commission
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Archived: Primrose House Residential Home

Overall: Requires improvement read more about inspection ratings

Perry Hill, Worplesdon, Guildford, Surrey, GU3 3RF (01483) 232628

Provided and run by:
Mrs Anne-Marie Antoinette Beeharry & Mr Ahmad Issac Beeharry

All Inspections

13 April 2015

During a routine inspection

Primrose House Residential Home provides personal care and support for a maximum of 16 older people, some of whom may be living with dementia. On the day of our inspection 15 people were living in the home.

This inspection took place on 13 April 2015 and was unannounced.

The home had a registered manager. 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 and associated Regulations about how the service is run. On the day of our inspection the registered manager was on annual leave and we were assisted by one of the senior carers.

Staff did not understand their responsibilities in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). People were restricted in the home without staff following the correct legal procedures.

Care was provided to people by staff who were trained, although we found staff had not received recent refresher training to keep them up to date with latest guidance.

Care plans were individualised and contained information to guide staff on how someone wished to be cared for. Care plans were reviewed regularly. However, we found some information was missing or not clear. For example, although we were told people felt safe and risks had been assessed around their mobility, other potential risks to people had not been assessed and recorded.

The environment was such that people may be at risk of harm. We found that staff had not upheld people’s dignity by ensuring people had hot water available to them.

We saw evidence of quality assurance checks carried out by staff to help ensure the environment was a safe place for people to live. However these checks had not identified the issue with the lack of hot water or the information recorded in care plans.

The management structure of the home was unclear in the absence of the registered manager.

Staff did not follow correct and appropriate procedures in relation to medicines to ensure people received their medicines safely.

There was a relaxed atmosphere in the home where people and staff interacted in an easy-going manner. People and relatives were happy with the care provided. Relatives were made to feel welcome when they visited.

There were a sufficient number of staff to care for people. Staff supported people to take part in various activities and arranged activities that meant something for people.

The provider had ensured safe recruitment practices were followed, which meant they endeavoured to employ staff who were suitable to work in the home.

People had care responsive to their needs. For example, one person required care in bed and staff provided this.

Staff were able to evidence to us they knew the procedures to follow should they have any concerns about abuse or someone being harmed.

People were provided with a range of meals each day and drinks and squash were available at all times for people.

Staff maintained people’s health and ensured good access to healthcare professionals when needed. For example, the doctor, optician or district nurse.

Complaint procedures were accessible to people. The provider had not received any written complaints.

People and relatives met together for meetings to discuss the running of the home.

During the inspection we found some breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

1 February 2014

During a routine inspection

We were unable to speak with all of the people at Primrose House due to their complex needs. However we spoke with three people who used the service, two relatives and four members of staff. We observed how staff interacted with people throughout the day.

Relatives we spoke with told us that they felt their family members were respected. One told us 'Staff talk to people ' it's more than just a job to them (staff).'

We saw during our inspection that staff were kind and caring with people. People and relatives told us that the staff were caring towards them. One person told us 'Staff are very kind.' We found peoples care plans reflected the care that was given.

Although the home was tidy we found that that the overall cleanliness and infection control needed improvement. This included the cleanliness of the bathrooms and the procedures for disposing of waste.

We found that there were effective recruitment procedures before staff commenced employment at the service.

We saw that that there were regular maintenance checks of all appliances in the home. However there were not sufficient systems in place to assess and monitor the quality of the service.

During a check to make sure that the improvements required had been made

We found the provider had ensured all current members of staff who administered medicines had support and training to enable them to administer and record medicines safely.

The provider worked in partnership with the GP to ensure that verbal instructions relating to medicines were followed up in writing by the GP.

24 January 2013

During a routine inspection

The registered manager was away on annual leave for two weeks. The relief manager assisted us on this inspection.

People said staff consulted with them, but the decisions were always theirs. People said they signed their care plans or their relatives signed on their behalf.This meant that people were involved in deciding their care and gave their consent for care to be carried out. Four people told us they did not know if they had a care plan. This could be because they had forgotten, as we found up to date care plans for them. One person said, 'I have a care plan and my relative and the manager review this with me on a regular basis".

People told us the staff spoke to them in a polite way and addressed them in the way they preferred. A relative said, 'I know my relative has a care plan. I was asked to sign it on their behalf and I have signed it. I am very involved in my relative's care'. One person said, 'The food is very nice and nicely cooked. It is well done. They know what I like and do not like'. Another person said, 'I get enough food'.

We found people expressed their views and were involved in making decisions about their care, treatment and support. People experienced effective, safe and appropriate care and were provided with suitable nutrition to maintain their wellbeing. We found staff had not always recorded medicines administered to people who used the service. However, people said they felt safe in the service.

16 August 2012

During an inspection looking at part of the service

Some people told us they could not remember if they had an assessment prior to being admitted into the service. Some people said someone from the service came to see them and asked a lot of questions, which they and their relatives answered.

27 October 2011

During a routine inspection

People who used the service told us they were involved in the planning of their care; that their named care worker discussed their support options and treatments with them and their family. Matters of personal care and hygiene and overall wellbeing had been discussed with them. They told us they attended review meetings often to discuss their needs and progress.

They said they were provided with the service user guide, and a contract of residency outlining costs and services which either they or their relatives signed.

Some people told us they could not remember if they had an assessment prior to being admitted into the service. Some people said someone from the service came to see them and asked a lot of questions, which they and their relatives answered.

People told us they had visits from their GP and they attended hospital appointments with a member of staff.

People said they felt safe in the service and they knew whom to speak to if they felt uncomfortable with a situation. They told us they would speak with the manager who would act on their behalf. They told us they had been provided with the service's service user's guide which contained information on keeping people safe, but they have never had to use it.