This comprehensive inspection took place on 31 October and 6 November 2018. The first day was unannounced. At the previous inspection completed in March 2018 we found staffing levels were not always sufficient to keep people safe. We also found improvements were needed in the recording of medicines and in ensuring the services quality assurance processes were robust.

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 t

This inspection was a focussed inspection which took place on 22 March 2018 and was unannounced.

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 comf

This inspection took place on 10, 11, and 17 October 2017. The first day of inspection was unannounced. This was the second comprehensive inspection of this service since it registered in October 2016. The previous inspection was completed in December 2016, following a number of concerns raised about the quality of care and support being provided. The previous inspection rated this service as overall requires improvement and found a number of breaches of regulation. These included Regulation 12- safe care and treatment. Improvements were needed in relation to medicines management, risk assessments and monitoring for pressure damage and poor nutrition and hydration. We also found people’s rights were not always being fully protected. This was because the service had not always applied the principles of the Mental Capacity Act 2005 to ensure people’s capacity had been fully assessed. Where people lacked capacity the service had not considered Deprivation of Liberty Safeguards or best interest decisions. We also found care planning was not person centred and their quality assurance systems had failed to ensure the service was safe and providing quality outcomes for people. We met with the provider to discuss the outcome of the December 2016 inspection. We also received an action plan about how they intended to make the necessary improvements to ensure they met the breaches we had identified.

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 compassi

Primrose House was registered in October 2016 to accommodate up to 30 older people. This was the first inspection since being registered. The inspection was unannounced and took place on 8 and 14 December 2016. We decided to complete this comprehensive inspection in light of receiving some information of concern and other safeguarding concerns which were being investigated by the local authority. Concerns included some people’s care needs not being met, lack of activities, poor management of falls, lack of personal care, staffing levels not being sufficient to meet peoples needs, management of medicines and pressure damage to skin. At the time of our inspection there were 11 people living at the service and one person who had been admitted into hospital.

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.

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