Primrose House

Primrose House is a service which provides care and support for up to 30 older people, some of whom are living with dementia. At the time of the inspection there were 19 people living at the service. The home is purpose built with communal spaces and bedrooms on each of the three floors.

Peoples’ experience of using this service and what we found

Our observations showed people appeared at ease with staff. A healthcare professional spoke positively of the service and the care and treatment provided. Risks of abuse to people were minimised because the service had safeguarding systems and processes. Staff understood safeguarding reporting processes.

The environment was safe. Health and safety checks, together with effective checks of the environment were completed. People’s medicines were safely managed, pre-employment recruitment checks were undertaken and there were sufficient staff on duty. The provider currently had a significant reliance on agency staff to ensure staffing levels were met. This was being addressed through a recruitment campaign to attract permanent staff.

People were supported to have maximum 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. There were systems in place to ensure that when people were deprived of their liberty, this was done with the appropriate legal authority. Where people had others acting lawfully on their behalf, appropriate records were maintained.

People, their relatives and a healthcare professional gave us positive feedback about the quality of care people received. The feedback about the registered manager from people and staff was positive. There were systems to obtain feedback from people, their relatives and staff. Quality monitoring systems were in place at service and provider level.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update:

The last rating for this service was Good (published 17 December 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 remained Good based on the findings of this inspection.

Follow Up:

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

Staff were aware of the correct personal protective equipment (PPE) they needed to wear to keep people and themselves safe. Staff confirmed they had not run low on stocks.

Staff were observed wearing PPE throughout the building and throughout the inspection.

Staff had training and support to understand the fundamentals of infection control and Covid 19. There was a contingency plan for if the service had an outbreak.

All visitors were only allowed into the home once they had declared their health status, provided their contact details and had their temperature checked. The provider had a separate visiting room just inside the main entrance. This meant families could visit without having to enter any of the communal areas. Visits were via prior appointment, and two per day were planned in. These had been temporarily stopped due to the new variant. We signposted the provider to national guidance about visiting for care homes.

Visits from family members had also included window visits and contact via phone and video calls. The exception being for people were at end of life care. In this instance family were supported to visit. This was done with full PPE provided and testing of those who would be visiting.

Staff testing was working well, and the service had completed a vaccination programme for people and staff.

Cleaning schedules had been increased to ensure high touch points were being cleaned. A new cleaner had been employed and this meant cleaning would be covered throughout each day and evening.

Following the last inspection, we met with the provider to their review their action plan and discuss what action was being implemented to improve the key questions of safe and well led to at least good. This meeting took place on 30 October 2018 and included discussion about a number of the providers other services.

At this inspection we found there had been improvements in the staffing levels which showed positive impact and outcomes for people living at the service. We saw that the introduction of a new manager and deputy manager had also impacted positively on record keeping and quality assurance audits.

Primrose House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Primrose House accommodates up to 30 people in one adapted building. The home is purpose built and set across three floors with bedrooms and communal spaces on each floor. All floors are accessible via a lift. Most people living at this service have conditions associated with old age, frailty and or dementia. At the time of the inspection there were 19 people living at the service.

A new manager has been in place for three months. They had applied to register with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The new manager together with the appointment of a deputy manager and activities coordinator had made a real positive impact for people. Staffing levels had been increased in line with the needs and increased number of people living at Primrose House. This meant care staff could spent meaningful time with people assisting them with all aspects of daily living. Staff were not task focussed and having more staff on each shift allowed them to deliver quality care and support to people. One staff member described how “We can spend time getting to know people better, taking our time to help them in the morning instead of running around like headless chickens.”

Improvements had been made to the governance of the service. This was because the manager and provider had worked in partnership with the local authority quality improvement team. They had produced an improvement plan which was being actioned. Audits and checks were being used to review all aspects of records and the environment. We have made a recommendation in respect of expanding this.

Staff and people said the new manager was open and inclusive. Staff felt valued and they said they had good training and support to do their job.

Medicines were being managed effectively to ensure people received their medicines on time. People’s healthcare was being monitored. Risks were identified and actions put in place to minimise any risks where possible.

People’s care and support was being planned in a person-centred way. Plans were detailed and included people’s wishes and diverse needs. People enjoyed a wide and varied choice of meals. Mealtimes were relaxed and enjoyable for people.

Recruitment was robust and ensured only staff who were suitable to work with vulnerable people were employed. Staff understood safeguarding processes to help keep people safe.

People were supported to have maximum choice and control of their lives and staff supported

them in the least restrictive way possible; the policies and systems in the service supported this

practice. People's consent to care and treatment was sought. Staff used the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and understood how these applied to their practice. A recommendation was made to ensure any approved DoLS were notified to CQC.

We completed this inspection to check on the welfare and safety of people following a number of concerns raised to the Care Quality Commission (CQC) about staffing levels and people’s needs not being met.

The team inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? This report only covers our findings in relation to these topics. You can read the report from out last comprehensive inspection, by selecting the ‘all reports’ link for Primrose House on our website at www.cqc.org.uk

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

When we last inspected the service in October 2017 we rated it overall Requires Improvement and found four breaches in regulation. These related to staffing levels, care planning not being person centred and quality monitoring not being robust. We met with the provider on 19 January 2018 to discuss the fact this was the second time the service had been rated as requires improvement. We also discussed their action plans to address breaches identified. The provider shared their action plan and discussed their plans to ensure there was a registered manager in post and more robust quality assurance processes being established.

Primrose house is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is purpose built and designed over three floors with lounge areas and bedrooms on each floor. Currently only two floors are in use. It is registered to provide care and support for up to 30 people. Most people using the service are living with dementia and or conditions associated with frailty. At the time of the inspection there were 12 people living at the service.

At the time of this inspection there was no registered manager in place. The provider’s quality assurance manager was overseeing this service and their sister home next door as an interim management arrangement. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Following the inspection the provider contacted us to let us know they had recruited an experienced manager who will be due to start at Primrose House in the next few months. They have also employed a care manager as a second level of management. This person began shortly after the inspection and was usually supernumerary to the care staff, but worked alongside them to ensure the shift ran smoothly.

We found there was not always sufficient staff available for the number of people, their needs and the layout of the building. This was supported by the views of staff, visiting relatives and healthcare professionals. When we fed this back to the provider, they agreed to immediately increase the staffing by one additional staff member. This meant there would be two care staff on each floor, with a care manager supporting them to provide safe and timely care and support.

Records in relation to one person’s medicines were unclear and we have issued a requirement notice in respect of this.

We found one airwave mattress which was set at the wrong setting for the weight of the person using it. The manager agreed to ensure daily checking took place as part of the comfort round/checks made by staff to people in their rooms. We made a recommendation to ensure this was being followed up.

Other risks were being safely managed with risk assessments and equipment being used when needed. Staff understood people’s needs and how to provide the right care and support to them. Staff were confident using specialist equipment such as hoists to safely transfer people.

Recruitment practices ensured only staff who were suitable to work with vulnerable people were employed.

Although we looked at some quality assurance processes, we did not fully inspect this area as there has not been sufficient time since the last inspection for the provider to show sustained improvements. We will check on this at the next comprehensive inspection later this year.

We saw incidents which should have been reported to CQC were now being notified. The management team understood their responsibilities to report and to keep people’s families and staff informed of developments.

We identified one further breach of regulation. You can see what action we told the provider to take at the back of the full version of the report.

Primrose house is registered to provide care and support without nursing for up to 30 older people. At the time of the inspection there were 15 people living at the service.

Primrose House is a purpose built service which sits alongside another home run by the same provider. Primrose House and the sister service Donnington House are run by the same registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The home also had a deputy manager who was fully involved in all aspects of the home.

During this inspection completed in October 2017, we found there had been some improvements. In particular to the way medicines and topical creams were being managed. We found risk assessments were being considered and documented, although records showed that where concerns had been identified such as weight loss, the care plan had not been updated to reflect the actions taken to mitigate this risk. We found some improvements with care plans, but some still lacked relevant details to enable staff to provide safe and effective care.

We saw staffing levels had been variable and at times lower than the providers preferred numbers. This had placed people at risk. For example on the weekend prior to the inspection there had only been three staff on duty and two people went missing within the building for a period of time. Both were vulnerable and should not have been left unsupervised.

The introduction of an activities staff member had impacted to some degree, but not enough, to demonstrate people’s social needs and stimulation were being met. We saw long periods where people were disengaged. At lunch time we observed a twenty minute period where vulnerable people had been left unattended. This was due to one person suddenly becoming unwell. However, staff from another area should have been alerted to cover the lunch period where people could have been at possible risk of choking.

People and relatives were complimentary about the care and support they received for. Comments included “The staff are really caring and cannot do enough for Mum.” and “If I ask one of the staff for help with anything they are always more than willing to stop what they are doing and make sure I get what I need.” We observed staff interacting with people in a kind, respectful and compassionate way.

The environment was kept clean and homely, although we fed back that there appeared to be a lot of information for staff pinned up in people’s lounge areas. This was removed once we gave feedback.

There was a good choice of meals and snacks being offered throughout the day. People said they enjoyed the food and were offered a variety. Comments included “The food and the choice is excellent.” and “My special dietary needs are catered for and I’m putting weight back on gradually now I’m here.”

Staff knew how to report any suspicions of abuse or concerns and were confident they would be dealt with. Staff recruitment ensured only staff who were suitable to work with vulnerable people were employed. There had been a number of staff leaving and new staff being recruited. This had affected staff morale. Staff said they were often asked to assist with care and support in their sister home next door, but when they were short this arrangement did not appear to be reciprocal. We fed this back to the management team. Having to cover for shortages at the sister home had further impacted on staff shortages at Primrose House.

Staff recruitment was robust and ensured staff were only employed once all the relevant checks were completed to ensure they were suitable to work with vulnerable people.

Some improvements had been made to quality audits but further improvements were still needed.

We found four breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.

Since this inspection was completed we have received a number of concerns about low staffing numbers. We have liaised with the provider who had assured us the staffing levels were being maintained at a safe levels. However a diarrhoea and sickness bug had meant that on some days, despite their best efforts staffing levels had fallen below the provider assessed and preferred levels. They have recruited more care staff, used agency workers and said they would not admit any new people into the service until mid-January once new staff had completed their induction.

Primrose House is a newly built service which sits alongside another home run by the same provider. Primrose House and the sister service Donnington House are run by the same registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The home also had a deputy manager who was fully involved in all aspects of the home.

Risks had not always been fully assessed to help keep people protected. Where people were at possible risk of developing pressure damage, there was not always a risk assessment with actions for staff to follow to reduce such risks. Care plan information was vague and did not fully describe what equipment was needed in helping to prevent pressure damage.

Where people were assessed as being at risk of poor fluid intake, the records were not always completed so there was limited information to demonstrate whether they had been supported to maintain a healthy fluid intake.

Care plans gave basic information and were not person centred. For example, they did not give any information for staff to help understand what the person’s life history was and what their preferred routines and wishes were. Without this essential information, staff would not be able to support people in a person centred way. One newer member of staff described how they were asked to help get people to bed at a certain time. They said they were aware people were settled and did not show any indication they wished to retire to their rooms at that time. The member of staff did question this practice but was told they should follow instructions. We fed this back to the registered manager and deputy manager who said there was no set time for staff to help prepare people to get ready for bed. They would investigate this issue and ensure all staff were aware that people should be assisted as and when they wanted to retire to bed. Other staff we spoke to knew that people could get up and go to bed whenever they liked.

As a new service in a new building with a new team of staff, the registered manager and deputy felt they may have tried to admit too many people within too short a space of time. They said this had been complicated further by several people displaying more complex needs than their initial assessment had indicated. This led to staff being overstretched trying to ensure people with complex needs were kept safe. They agreed that this had meant for a short period, that people with less complex needs may not have received the care and support they always needed. For example allowing extra time to ensure staff could go back to people who were initially reluctant to accept personal care. We found there were sufficient numbers of staff on during the inspection. The registered manager and deputy said they had learnt from this difficult period that they needed to ‘take stock’ and not admit any more new people until they had all their records, plans and training of staff up to speed.

Staff described how on occasions, for some people they needed to use safe holding to ensure they were able to complete personal care without the individual or staff being harmed. Staff had not received training in such restrictive measures. Advice from the mental health team had been requested for guidance with people’s care.

Restrictions such as pressure mats, bedsides and locked doors were being used to keep people safe. The deputy manager said she had been making some urgent applications to the local authority for Deprivation of Liberty safeguards (DoLS) but this was not documented within care plans. Staff were not always aware of who had applications pending. We observed one person asking to leave and trying to get out of the patio doors. They did not have a DoLS authorisation or application pending. The deputy manager said the person was the next on the list and agreed they would make an urgent application as soon as possible. This had been completed by the second day of our inspection.

Some newer staff were not aware of which topical creams should be applied to which parts of people’s bodies. The service had a form and body maps to guide staff but these had not been used. The deputy manager said she would ensure these were in place for each person by the end of the day. They said they would make sure staff had access to this information within the care and daily notes they used on each floor for easy and quick reference. By the second day of the inspection these were in place.

There were enough staff with the right skills for the current number of people living at the service. A dependency tool had not been used to determine the staffing levels. The registered manager assured us, this was being kept under constant review in line with people’s changing needs. She gave the example of one person whose needs suddenly increased and she decided in order to keep them safe whilst an alternative placement was being sought, that they would provide one to one staffing for this person.

People and their relatives described staff as caring and kind. One relative said that although there had been some initial ‘teething problems’ they were ‘‘overall satisfied with the service. Staff really good.’’ Another visitor said ‘‘I can’t fault the service, staff are wonderful. I can visit when I like and am offered a meal if I wish, which they don’t charge me for. Building really lovely and care staff brilliant.’’

During our visits people said they were happy with the meals offered. We observed lunchtimes to be relaxed and social occasions. Staff assisted people and encouraged those who were reluctant to eat to try some of their food. Staff engaged with people in a kind and respectful way. People were offered a variety of choices throughout the meal such as what drinks they would like and whether they wished to have more food.

There were quality assurance systems in place but these were not fully effective.

There was a strategy meeting held on 13 December 2016. The registered manager and deputy manager attended. An action plan was agreed, which included agreeing not to admit any more people until the New Year or until better systems were in place. The management team based at the home accepted the findings of the meeting. The local authority quality assurance team would provide support to the home. CQC will be meeting the provider in January 2017 to discuss their action plan and will be visiting again within three months to ensure that all requirements are met. The registered manager and deputy manager have kept CQC up to date with all matters requested following the inspection.

There are five of breaches of regulations. You can see what action we took at the end of the report.