Primrose Hill Care Home

Updated 6 October 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors carried out this inspection.

Service and service type

Primrose Hill Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Primrose Hill Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with four people who live at Primrose Hill Care Home. We also spoke with the registered manager, regional operations director, deputy manager, two care assistants and a member of the domestic team.

We reviewed a range of records. This included care records and medication records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We requested some further records after we had visited the home so that we could conclude the inspection.

Updated 6 October 2022

About the service

Primrose Hill Care Home is a care home providing accommodation, nursing and personal care to older people and people living with dementia in one purpose built building. The service can support up to 60 people. At the time of our assurance visit there were 50 people using the service.

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

An action plan had been put in place in response to areas for improvement being identified following a visit from representatives of the Cambridgeshire & Peterborough Integrated Care System team. However, the action plan had not always been followed to ensure the improvements had been sustained. This had meant that people had not always had their wounds reassessed or dressed as planned. Food and fluid intake records and records for repositioning for those at risk of pressure ulcers had not always been updated by staff to demonstrate the care and support given. These records were also not reviewed by staff each day as required by the services action plan to ensure people were receiving the support they required.

People told us they felt safe living at Primrose Hill Care Home. Staffing levels had recently increased in response to a visit carried out by representatives of the Cambridgeshire & Peterborough Integrated Care System team. Staff told us that the increased staffing levels meant that they could spend more time with people. People received their medicines as expected. The prevention and control of infection was managed safely and in line with government guidance. Staff had been recruited safely and understood their responsibilities to keep people safe.

The registered manager was committed to addressing shortfalls identified during the inspection visit and driving forward improvements.

People were supported to have 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.

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 good (report published 02 September 2019).

Why we inspected

We received concerns in relation to people’s safety and the management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. The registered manager took action during the inspection to ensure risk assessments and care plans were updated as necessary.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Primrose Hill Care Home on our website at www.cqc.org.uk

Enforcement

We have identified a breach in relation to actions within the services action plan were not always followed to check care and support was being carried out as expected. This would ensure people’s needs were met in a timely manner.

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

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.