Primrose Hill Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance at the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always create a positive culture.

Although there were processes in place to ensure there was a positive culture in the home such as; ensuring the wellbeing of staff and ensuring staff had received training that gave them the skills and knowledge to promote a positive culture, we could not be assured this was effective. Staff told us they did not feel confident to speak out during the site visit and shared concerns with us after the inspection.

Not all leaders understood the context in which the provider delivered care, treatment and support.

The lack of effective systems and oversight of the care people received demonstrated a lack of capability within the management and leadership team. There was also a failure by all leaders to have adequate oversight of the staffing levels of the home. There were people living at the service who had a learning disability, including 1 person whose primary care need was their learning disability. The provider and registered manager had not identified the service did not have the required service user band of learning disabilities on their registration.

People and relatives knew who the registered manager was. Care staff were aware of their roles and responsibilities and when they needed to escalate concerns.

The team was aware of and understood their legal responsibilities around notifying CQC about any important events that had happened in the service.

The culture of the service meant the provider failed to work transparently. The provider had failed to develop an open and honest culture where they worked openly with people, their families and other professionals to share concerns.

Some staff felt they could not always speak up. Before and after our inspection we received information of concern from staff. They told us they had raised concerns with us outside of the inspection process as they did not feel comfortable doing so whilst we were on site and were concerned about the consequences. Other staff felt they were able to raise concerns.

There was a whistleblowing policy in place that staff were aware of and the procedures they needed to follow. The registered manager also told us staff could raise concerns if needed through their supervisions.

The provider valued diversity in their workforce.

There were procedures in place to consider staff’s individual needs, which included considering staff’s diverse needs and treating all staff fairly and equitably. Staff felt they were treated in an inclusive way.

There were some audits in place however they were not always effective in identifying areas of improvement. There was a system in place to monitor medicines, however it had not identified the concerns we found with the storage of medicines or stock levels. This meant it was not effective in identifying all areas of improvement.

Other audits had also not identified all areas of improvement. For example, the internal IPC audit had not identified any concerns and had not identified the external concerns identified by the IPC team. The concerns with the environment had not been identified though environmental audits that had been completed.

There was no effective oversight or system in place that ensured people were receiving the correct levels of staff support.

Although the registered manager told us improvements were needed to care plans and risk assessments, no effective audit had been completed to identify where these improvements were needed or to prioritise addressing these.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

There were systems in place to ensure the provider worked in partnership with other agencies. As part of this assessment, we asked the Local Authority for feedback, they told us they were working with the home after identifying areas of improvement. They told us there was an action plan in place that the home was working through.

The provider did not always focus on continuous learning, innovation and improvement across the organisation.

The systems in place were not effective and had not identified all concerns and driven improvements, which meant learning opportunities were missed.