Primrose House

People’s experience of using this service and what we found

People, relatives and staff felt the home had improved since the last inspection. The provider now had a more structured approach to quality assurance (QA); however a small number of audits hadn’t been completed consistently. Management reviewed the findings from audits, but the system needed a more in-depth analysis of findings to ensure lessons were learnt and shared. Particularly in relation to incidents, safeguarding concerns and complaints. Medicines were managed well, however records to support staff in their safe use required improvement. We have made a recommendation about this.

Opportunities for people, relatives and staff to share their views had improved. People and relatives gave positive feedback about the care provided. Staff felt morale, teamwork and the atmosphere in the home had improved.

There were enough staff to meet people’s needs and new staff were recruited safely. Some relatives felt there had been a lot of staff changes recently. Some staff interacted well with people but this was inconsistent, especially in one particular area of the home.

The home was clean and staff followed the provider's IPC practices. A new system had been implemented to deal with laundry to help prevent the spread of infections.

People were supported to have enough to eat and drink. Changes had been made to improve people’s dining experience.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service this practice.

Opportunities for people, relatives and staff to share their views had improved.

The quality of people’s care plans had improved and were much more personalised. They included information about people’s preferences and what they were able to do for themselves.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 17 December 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements, however the provider continued to be in breach of regulation 17.

At our last inspection we recommended that the provider reviews how staff were deployed. At this inspection we found this had been completed and improvements made.

Enforcement

We have identified a continued breach in relation to medicines records.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Primrose House is a residential care home providing personal and nursing care to up to 63 people. The service provides support to people aged 18 and over, some of whom were living with a dementia. At the time of our inspection there were 55 people using the service.

People’s experience of using this service and what we found

The provider of the service had recently been purchased by another provider, and there was a new board of directors and senior management team. The previous manager and nominated individual had left the service, and the new management team had only been responsible for the home for a few weeks. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

People were not protected from the risk of infection. Staff did not always wear PPE or wear it appropriately when supporting people. We requested that the premises, furniture and equipment were deep cleaned, repaired or replaced.

People and their relatives gave mixed reviews about the care provided. Relatives were concerned they had not been able to visit people regularly due to frequent outbreaks of infections. Relatives told us people’s rooms required cleaning and items of clothing frequently went missing.

People did not receive dignified person-centred care. During the inspection we observed people wearing unclean clothing and sitting on soiled chairs. One person asked inspectors to support them to the toilet and another to get them a drink, as no staff were available. People were not supported in line with their care plans.

Risks were not always safely managed. Environmental risks had not been fully mitigated. We found actions detailed on the fire risk assessment had not been completed and fire risks were still present at the home. We requested that the local fire officer attended the home to support the provider to make changes to keep people safe. Assessments did not always include all information for staff to follow to keep people safe.

People did not always receive their medicines safely and staff were not always following national best practice guidance for safe medicine administration. Agency nursing staff did not always have competency assessments in place to administer medicines. Records did not show that people who were receiving special diets, were given appropriate meals or drinks .

The provider had assessed the staffing levels required to safely support people and staffing levels matched the dependency levels. We did observe that staff deployment across the home was an issue and the management team agreed to review this. Staff had not fully completed all mandatory training as dictated by the provider.

We have made a recommendation that the provider reviews the deployment of staff throughout the home, to ensure that people can be safely supported.

People had care plans in place, but these required a review. Information within care records was sometimes contradictory or did not include all of the relevant information for staff to follow to support people.

People’s needs and choices were assessed and incorporated into care plans. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There was a negative staff culture amongst the majority of staff. Some staff were very positive and went the extra mile for the people they supported. Due to staff deployment and recruitment issues there were no meaningful activities offered to people. Some staff used their days off work to take people out or spend time with them.

The quality and assurance systems in place had not been completed or effectively used by the previous management team . We found some checks and audits had not been completed for over 6 months and there had been no provider oversight during this time.

The new senior management team had undertaken a detailed audit of the service which highlighted the majority of the issues identified during the inspection process. We were assured that plans were in place to improve the service, with regular involvement from the infection prevention and control team at the hospital, the local authority and health commissioners.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 11 October 2019).

Why we inspected

The inspection was prompted in part due to concerns received about the safety and quality of care provided to people. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report. We have assurances that the issues identified are being acted upon by the management team and a pro-active response was taken during the inspection process to start addressing the areas of concern.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to medicines management, person-centred care, infection and prevention control measures and the quality and assurance systems in place at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We are currently meeting with the provider in partnership with the local authority and other agencies to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We will request an action plan, following the report being published, from the provider to understand what they will do to improve the standards of quality and safety.

We found the following examples of good practice.

• Systems were in place to help prevent people, staff and visitors from catching or spreading infection.

• The environment was clean. Additional cleaning was taking place, including of frequently touched surfaces.

• Staff wore appropriate PPE and there were sufficient supplies. The manager carried out weekly checks to ensure the service always had enough PPE for staff to access and that it was stored appropriately.

• Staff had undertaken training in putting on and taking off PPE and other COVID-19 related training.

• People and their relatives were supported to keep in contact using a range of technology as well as visits to the home in line with government guidance.

• People and staff participated in a regular testing programme.

• Appropriate vaccination status checks were in place.

Primrose House is a residential care home providing personal and nursing care to 49 people aged 65 and over at the time of the inspection. The service can support up to 63 people across four floors.

People’s experience of using this service and what we found

There was an embedded culture in the service of ensuring people continued to lead fulfilling lives. People were provided with meaningful activities to significantly enrich their lives, retain their skills and develop new ones. They were supported by staff who overcame barriers to people’s participation in activities which were socially important to them. The service had forged good links with community-based groups and projects which had been brought into the service. These had enhanced people’s lives. People benefitted from the use of technology and the many and varied social activities on offer.

Care plans were person-centred. Staff were given good guidance on how to meet people’s needs. The provider had developed a strategy to assist staff to provide end of life care in keeping with national standards.

Staff understood people’s personal risks and how to keep them safe. The provider had arrangements in place to ensure people’s medicines were appropriately managed. Risks of cross infection were minimised by regular cleaning, and staff wore gloves and aprons when they supported people with their personal care.

Before staff had begun working in the home checks on their suitability had been carried out. Once employed, staff underwent a period of induction and training. Staff undertook training in topics relevant to people’s care needs. They were supported through supervision. There were enough staff on duty.

Staff were kind and caring towards people. They respected their choices and preserved their dignity and privacy. Respect for diversity was evidenced in the home and people were supported with their religious or spiritual needs.

The provider had frameworks in place to ensure continuous improvement. Regular audits resulted in actions to be taken. The provider followed up on the actions and checked if they had been done to an acceptable standard.

There was close working with other professionals to meet people’s needs.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection.

The last rating for this service was requires improvement (published 5 September 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

During this inspection we found a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations: Safe care and treatment, regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations: Good governance, regulation 18 of the Care Quality Commission (Registration) Regulations 2009: Notification of other incidents and regulation 20A of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations. This was because the provider had not adequately assessed the risks to the health and safety of people using the service, the management of medicines was not safe, renewal applications for the deprivation of liberty safeguards were not notified to the Commission and the provider did not display the previous rating within the home clearly or on the website. In addition to this provider did not operate robust governance arrangements to monitor and improve the service provision they provided to people. You can see the action that we have asked the provider to take at the back of the full version of this report.

There was a registered manager in post who has been registered with the Care Quality Commission (CQC) to provide regulated activities since November 2015. 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.

People told us that they felt safe at the home and relatives agreed with these comments. We found there were policies and procedures in place to help keep people safe. Staff had received training and attended supervision sessions around safeguarding vulnerable adults. Staff were safely recruited and they were provided with all the necessary induction training required for their role. The registered manager continued to provide on-going training for staff and monitored when refresher training was required but not all staff had attended refresher courses. Staff had received training in end of life care and the service worked closely with partnership agencies to deliver this when required.

Accidents and incidents were recorded correctly and if any actions were required, they were acted upon and documented. We observed that there were enough staff on duty to support people appropriately in line with their assessed needs.

During our inspection we found that the premises were not always safe for people living at the home. We found the main conservatory doors open, sluices unlocked, fire doors stating, “keep locked” were open, the laundry room was open for people to access, clinical waste bins were open and bathroom pull cords were propped out of reach.

Regular checks of the premises, equipment and utilities were carried out and documented. Infection control measures were in place and the service was clean. We saw domestic staff cleaning the home regularly during inspection.

The home did not always provide safe medicine management. During the inspection we observed an unattended and unlocked medicines trolley left in front of the open conservatory door. Procedures were in place to ensure the safe receipt, storage, administration and disposal of medicines. There were records regarding other professionals involved in people's care. People’s medicine care plans did not always fully document all of the information needed to fully support people.

People were supported to maintain a balanced diet and we saw people had access to a range of foods and fluids throughout the day. We observed a positive dining experience at the home and relatives also commented to us that they were pleased with the range of food provided.

The premises were 'dementia friendly' as the walls, floors and doors were painted in contrasting colours and there was pictorial signage to help people orientate themselves.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. Staff demonstrated their understanding of the MCA. The registered manager had made applications on behalf of most people living at the service to restrict their freedom for their own safety in line with the MCA. The registered manager had not notified CQC of these applications.

We saw staff asking people for consent when supporting and asking for people's choices for meals and drinks. Staff treated people with dignity and respect. They showed kind and caring attitudes and people told us the staff spoke nicely to them. We observed people enjoyed positive relationships with staff and it was apparent they knew each other well. People and relatives knew how to raise a complaint or concern. There was information on how to make a complaint displayed within the service and this was accessible to everyone. Feedback was sought from people, relatives and visitors to help continuously improve the service.

People had person-centred care plans and risk assessments in place to keep them safe. People, relatives and external health professionals were all involved in best interest decisions and mental capacity assessments. People's care records were accurate and up-to-date.

The provider and registered manager had a clear vision to care for people living at the home. Staff told us that they could approach the registered manager if they needed support or guidance. Relatives said that they were always welcome at the service. The registered manager carried out regular checks and audits of the service and worked with the provider to achieve positive outcomes for people who used the service.

People’s privacy and dignity was respected by staff. During the inspection we observed staff asking people discretely if they could carry out personal care and if they required support. The service promoted advocacy and there was accessible information available detailing what support people could access to help make choices about their individual lives.

This was the first inspection of this newly registered service. The service was called St Oswald’s Care Home at the time of this inspection but has since been renamed Primrose House.

Primrose House is a care home for older people, some of whom have a dementia-related condition. It provides nursing care. It has 65 beds and had 43 people living there at the time of this inspection.

The service 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 2008 and associated Regulations about how the service is run.

People told us they felt the staff kept them safe and well-protected. People’s relatives confirmed this. No-one expressed any concerns regarding people’s safety. Risks to people were regularly assessed and appropriate measures were put in place to minimise any risks identified. There was a low level of accidents in the home. People were supported to take their medicines safely.

Staff had been trained to recognise and respond quickly to any abuse, neglect or poor practice. Safeguarding issues were reported to the appropriate authorities.

Regular checks were undertaken to ensure the building was safe. Systems and equipment were regularly serviced, and repairs were completed promptly. Plans were in place for dealing with any building or other emergencies.

Staffing levels were sufficient to meet people’s needs safely and appropriately. People told us staff responded quickly when they needed them. Extra staff were provided when people’s needs changed. Systems for recruiting new staff were robust and ensured only people fit to work with vulnerable people were employed. Staff were given the support they needed to perform their roles effectively, by means of regular supervision, training and annual appraisal.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005. These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. Where it was deemed necessary, written applications had been submitted to the local authority for authorisation to restrict people’s liberty.

Appropriate assessments had been undertaken of people’s capacity to make particular decisions. Where people lacked such capacity, appropriate ‘best interest’ decisions had been taken, with the involvement of the person’s family, and these were clearly recorded. People were asked for their consent before staff members carried out any care tasks or other interventions.

People’s health care needs were closely monitored and were met using the support of a wide range of external health professionals. People’s nutritional needs were assessed and they were supported to enjoy a varied and healthy diet.

People and their relatives told us the staff team was very caring, and treated them with sensitivity and respect at all times. We observed staff were attentive and responsive to people’s needs, and affectionate in their approach. Staff were careful to protect people’s privacy and dignity, and encouraged them to be as independent as they were able.

People were provided with information about their care and about the running of the home, were asked their views and could access advocacy services if needed.

When assessing people’s needs, the views and preferences of the person and their family were sought and were included in the care plan drawn up to meet those needs. Care plans were kept under constant review and were updated as required. Meetings were held with people to discuss their care.

A range of social activities were available to people, and there were plans to increase the range of activities and other social stimulation, with more trips out.

The service was well managed. There was an open and reflective culture in which the people living or working in the home felt valued and respected. Staff morale was high: staff told us they enjoyed their work and were proud of the care they provided. People and staff commented very positively on the many improvements to the service over the previous year.