Primrose Lodge Care 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 changed to good. This meant people were safe and protected from avoidable harm. The provider was no longer in breach of legal regulation in relation to medicines management as identified at the last assessment.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was evidence of lessons learned when things had gone wrong and this information being shared with the staff team.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff understood their role in supporting people to access appointments. Records showed people had access to a range of health and social care professionals when needed. People were assessed before they moved into the service and this information was used to develop care plans. Policies and procedures ensured a consistent approach to recording, understanding and acting on risks.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.
People were safe from abuse. Safeguarding concerns were raised and dealt with accordingly. However, paperwork was not always completed in line with procedures. Safeguarding formed part of the induction and ongoing supervision with staff, who were confident how to report concerns.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Risks to people’s health, safety and welfare had been assessed. This covered all key areas, including falls, nutrition, and skin integrity, along with individual identified risks. Risk assessments were person-centred. Safeguards were not unnecessarily restrictive, and people’s rights and freedoms were respected.

When asked whether they thought a person was safe at the service, a relative said, “Yes, it’s partly safe. I have observed what is happening. The staff are doing a reasonable job. Mostly, someone is with [person] and other residents in the lounge. [Person] has a brand new wheelchair. [Person] has no recent bruises, sores or falls.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

At the time of the inspection aspects of the service were worn, tired or damaged; particularly some of the bathrooms. The provider had identified the areas that needed improvement and were working through an action plan to refurbish the service.

The provider did not always make sure there were enough qualified, skilled and experienced staff. However, staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff available to support people with care and during mealtimes however, there was not always enough staff to support engagement in activities.

Staff were recruited safely in line with best practice guidance. Most staff received regular supervision and appraisals however, there were some staff who were overdue supervisions. Staff had received training including specialist training to support people with complex care needs.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some areas of the service were damaged which meant they could not be cleaned effectively including shower chairs, seats in the lounges and flooring. On the first day of inspection the tea trolley was unclean and there were dirty cups in a kitchen cupboard. Improvements had been made by the second day of inspection. The provider had a plan to made improvements to the damaged furniture.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Systems were in place to make sure people’s medicines were administered safely. Stock balanced with records and a running balance was in place for assurance. Time sensitive medicines were given correctly.

People’s medicines allergies were recorded accurately. We observed medicine administration to 2 people; staff were respectful, and people were given the time they needed.

Guidance was available for creams applied by care staff as part of personal care; however, records were not fully completed. Patch application records did not always demonstrate rotation in line with manufacturers guidance to prevent side effects.

Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Information for how these medicines should be administered had been updated to include person-centred information, but others needed further person-centred detail.

Information on how people took their medicines if given covertly or via a PEG was not sufficiently clear. The manager said they would review this after our inspection.

Medicines were stored securely including controlled drugs. Temperatures were recorded for the medicine rooms and fridges; however, the fridge maximum temperature had been out of range and had not been investigated to ensure medicines were safe to use.

Comprehensive policies and procedures were in place to support the administration of medicines. Audits had picked up some of the issues we found.