Primrose Hill Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to people’s safe care and treatment, medicines management and staffing.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice.

There were systems in place to ensure lessons could be learnt and improvements made to the service where needed. When incidents had occurred the leadership team had reviewed these, reflected on these and considered how things could be completed differently in the future. Staff confirmed they attended team meetings where learning was discussed. However, these systems were not always consistently and effectively used in all areas. For example, care plans and risk assessments had not always been reviewed effectively to ensure they were up to date, and all risks were mitigated. This information was not always reviewed so that lessons could be learnt.

Despite the registered manager telling us where improvements were needed in the home, there were not always formal plans in place to evidence this that identified how improvements would be achieved; this meant we could not be assured all areas of learning were considered.

The provider did not always ensure, establish and maintain safe systems of care.

There were systems in place to ensure people’s needs were assessed before they started using the service. This included both record-based and face to face assessments. The registered manager told us when someone new started using the service they would implement a 72-hour care plan so they could review the person before implementing the full care plan.

However, we found people did not always have detailed care plans or risk assessments in place based on these assessed needs. Some care plans were not in place at all. For example, a person who staff had identified as being at risk of self-harm, did not have a care plan in place for this specific element of their care. It was also not always clear how people and other people that were important to them were involved with the process. This placed people at risk of receiving unsafe and/or unsuitable care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

People felt safe living in the home. One person told us, “On the whole I feel safe and looked after”.

There were systems in place to ensure safeguarding concerns were identified, reviewed and investigated. When needed concerns had been shared with the safeguarding team to ensure appropriate action could be considered. Staff told us they had received training in this area and were aware of what action to take if they were concerned.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In [care homes/hospitals], this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS applications and authorisations were in place for people.

Risks to people were not always managed in a safe way.

We received mixed views on how well people’s risks were managed. One person who raised concerns to us went on to conclude, “In the evening this is a different place, with people wandering around aimlessly. Some are noisy”. A relative told us they felt their relation was, “Safe in bed but not in the lounge”. Other people and relatives raise no concerns with 1 relative commenting, “I would say that the environment is safe and there are no risks at the moment”.

We saw some people walked with purpose around the home, this posed a risk to themselves and others. They were able to access people’s bedrooms unsupervised, including people’s bedrooms who had known behaviours that may challenge. We saw 1 person go into a person’s bedroom, as no staff were present to offer support, they tried to remove a sensor that was in place to keep them safe, we intervened and shared this with the staff. This placed people at an increased risk of harm.

Care plans were not always consistent, up to date or in place. Some of the care plans we viewed lacked detail or were not accurate. For example, 1 person’s care plan had not been updated to accurately reflect the number of staff they needed to mobilise. Another person did not have a care plan in place for the times they experienced emotional distress. We shared this with staff who took action and created this care plan; however, they did not involve the person with this and the care plan lacked detail to keep the person safe. Another person’s care plan for pressure management was not consistently followed and the wound had not been assessed in line with the plan that was in place. Not having accurate and up to date care plans in place, placed people at an increased risk of harm.

However, we found examples of some appropriate risk assessments that were regularly reviewed, including how people were supported with their dietary needs.

The provider did not always detect and control potential risks in people’s home environments.

We received mixed feedback on the safety of the environment. Most people told us they were happy with it, however 1 person said, “This is not the best environment, some of the noises get to you.” Another person raised concerns to us about the toilet seat in their ensuite bathroom. We saw the seat was insecurely fitted. We saw on 1 of the floors a hot trolley was left in the communal corridor unattended, and people were walking with purpose in this area. This all placed people at an increased risk of harm.

The registered manager when asked told us they had not been made aware of these concerns and the audits in place had not identified these.

The provider did not always make sure there were enough staff available to support people.

People and relatives told us staffing levels were not always adequate. One person said, “They are always short of staff”. Another person said, “When I press the buzzer, they come when they feel like it. I keep pressing the buzzer till they come”. A relative told us, “They are lacking in staff for a complex needs unit and this is wrong. You have 3 carers on the floor but with people with challenging needs things can change very quickly. For 13 residents 3 carers are not enough.”

Staff and professionals also raised concerns with us. One staff member said, “100% not enough staff.” Another staff member told us, “It depends on the residents on the day, good days and bad days, sometimes it is tough, we could do with 3 [care] staff on each floor I think”. After our inspection we continued to receive concerns about the staffing levels within the home.

There were not always enough staff available to support people when they needed it and to keep them safe, we have reported on these concerns under ‘involving people to manage risk’.

In addition to this, at lunchtime people did not always receive the support they needed. In the communal dining room, we saw there was only 1 staff member available to offer support. People were not always encouraged to eat as there were no staff available to offer support, people did not always finish their meal, and this was taken away from them without carers being present to offer encouragement. When people were eating in their rooms, some food and drinks were left next to people while they were sleeping and some meals were left out of reach and again staff were not available to encourage or support people with this. Some people had to wait for staff to become available before they were assisted with their meals, on 1 occasion this was over 30 minutes after their meal was served.

The dependency tool the provider had in place to work out the number of staff that was needed in the home was ineffective. The operations manager told us they had recognised this as this tool did not consider the clinical tasks nurses completed. We saw the nurses were counted in the numbers of staff that the dependency tool calculated was needed, meaning the tool was not effective. The registered manager told us nurses were available to support staff to assist with people. However, we saw this was not accurate. We saw nurses were unavailable to offer assistance as they were completing medicine rounds and other clinical tasks. Furthermore, we saw 1 nurse spend time with visiting professionals. The nurse sat with the professional for the duration of this visit and a nurse from another floor was called to cover this nurse’s clinical tasks, meaning they were not available on the floor they had been allocated to. This all demonstrated that there were not enough staff available for people and the tool used was not effective.

We shared our concerns with the registered manager who took action to temporarily increase the staffing levels in the home. The provider had also recognised the dependency tool in place was not effective and was in the process of implementing a new one. We will review this as part of our next inspection.

People and relatives raised no concerns around the knowledge and training of staff and felt they had the skills to support them safely. Staff had received training to ensure they had the relevant knowledge and skills to support people. Staff spoke positively about the training they received. We saw there was a training matrix in place which monitored staffs’ training needs.

Staff had received the relevant pre-employment checks before they could start working in the home to ensure they were safe to do so.

The providers’ systems did not consistently ensure the risks associated with cross infection were minimised.

We saw the home was clean and people were protected from the risk of cross infection. However, we saw 1 person was handling dirty laundry which had been left unsupervised as there were no staff available to offer support to this person. This placed people at risk of cross infection.

There were processes in place to ensure concerns with IPC were identified so that appropriate action could be taken, however this was not always effective as a recent external IPC audit had been completed, and the provider’s audit had not identified all the concerns raised by the IPC team.

People and relatives raise no concerns about the cleanliness of the environment. Staff told us they had received training and there was enough Personal Protective Equipment (PPE) available for them to use.

Medicines were not always stored securely. One person was self administering their medicines which were stored in their bedroom. We saw they had a large amount of stock medicines which were not stored securely. We also saw their ‘in use’ medicines were stored in a lockable portable drawer; however, this was unlocked and some of their medicines were stored on top of the drawer.

We also saw some prescribed creams were on shelves in people’s bathrooms, again insecurely stored. This all-placed people at risk of potential harm as these medicines could be inappropriately accessed, misused or tampered with.

We raised our concerns with the registered manager during our inspection who took immediate action to resolve this.

We found some stock checks of people’s medicine were inaccurate. This had not been identified by staff and the provider’s audits had not identified these concerns. We therefore could not be assured people had consistently received these medicines as prescribed.

When people had ‘as required’ medicines there was guidance in place for staff to follow. Staff administering medicines had received training and their competency was checked to ensure they were safe to administer these to people.

People and relatives were happy with how medicines were administered. One person said. “I always get my medicines on time”.