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Primrose Hill Nursing Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 4 June 2020

About the service

Primrose Hill Nursing Home Nursing Home provides personal and nursing care for up to 50 younger or older adults who have a variety of needs due to their mental health, physical disability, or sensory impairment. There was 30 people living at the home on the first day of our inspection.

Primrose Hill Nursing Home which was built for purpose has three units across three floors, At the time of our inspection the ground floor was in use as a dementia care unit. The first floor was a nursing unit with the third floor in use as staff training and accommodation.

The inspection was conducted over three separate days. The third day of the inspection was prompted by concerns received about a safeguarding alert that was initially raised by the provider. A decision was made for us to inspect and focus on interviewing staff and to look at their support, and how there would not be a repeat of these risks. This incident is subject to a possible criminal investigation. As a result, this inspection did not examine the circumstances of the incident, but we did consider the provider’s initial responses and how these would ensure people’s safety. We found no evidence during this inspection that any people were at an ongoing risk of serious harm from this concern. The provider had taken steps to reduce the risk to people following learning from this incident and was making some significant changes to improve people’s safety that were in the process of implementation on the last day of our inspection.

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

The service had not had a consistent manager on site to provide leadership at the home since it was first registered, and home manager had only been appointed a few months before. People's feedback about the new manager was positive and the wider senior management team were open and honest about the improvements that were needed. This included better leadership, more consistency with staffing, improvement in record keeping and care planning and better risk assessment. Quality monitoring systems were being developed but there was further improvement needed so these were more effective. Work on these systems was underway during the inspection.

People's care plans and risk assessments did not always reflect people’s needs and preferences although staff demonstrated an awareness of people’s needs, likes and dislikes. Staff were able to explain, or we observed them provide appropriate, safe care that reflected people’s needs and preferences.

People were not consistently safe although staff had a good awareness of what to do to minimise risks of harm or injury to people as far as possible without infringing their rights. There were occasions though where documentation to ensure staff were well informed of all potential risks to people was not fully completed.

Most people were satisfied with how their medicines were managed, but there had been occasions where systems had not ensured people’s medicines had always been available. Further consultation with stakeholders and other health care providers was needed to avoid any repeat of these incidents.

There was enough staff available to keep people safe and staffing levels were reviewed and changed to reflect changes in people’s needs, although reliance on agency staff to maintain staffing levels had impacted on the consistency, and safety of care at times. The provider was committed to stopping the use of agency staff for these reasons and was recruiting staff and limiting admissions to ensure this was achievable.

People were supported by care staff who had the skills and knowledge to meet their needs. People expressed confidence in staff skills and knowledge and staff understood, felt confident and well supported in their role. People's health was supported as staff worked with health care providers, whether on or off site, as needed to support people’s healthcare needs.

People were supported to have choice and control

Inspection areas


Requires improvement

Updated 4 June 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 4 June 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 4 June 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 4 June 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 4 June 2020

The service was not always well-led.

Details are in our well-Led findings below.