Archived: Primrose Hill

Updated 27 January 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on the 26 November 2014 and was unannounced. The inspection team consisted of two adult social care inspectors.

We used a number of different methods to help us understand the experiences of people who used the service. During our visit we spoke with seven people living at the home, two relatives, six members of staff and the manager. We spent some time observing care in the lounge and dining room areas to help us understand the experience of people living in the home. We looked at all areas of the home including people’s bedrooms, communal bathrooms and lounge areas. We spent some time looking at documents and records that related to peoples care and the management of the home such as training records and policies and procedures.

Before our inspection, we reviewed all the information we held about the home. The provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

Updated 27 January 2015

We inspected Primrose Hill on the 26 November 2014 and the visit was unannounced. Our last inspection took place in November 2013 and at that time we found the home was meeting the regulations we looked at.

Primrose Hill is a purpose built home. It is owned and maintained by Leeds City Council. The home provides care for up to 33 people. It is set in a quiet location in Boston Spa close to the local shops, pubs and a post office. Accommodation is in single rooms and there are also well-equipped assisted communal bathing facilities. Lounge and dining facilities are situated on two floors.

There was a registered manager in post. 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.’

We were told by the registered manager the home has been earmarked for closure. This would be done when permanent residents no longer needed the service. However no time scale has been specified.

The experience of people who lived at the home was positive. People told us they felt safe living at the home, staff were kind and caring and they received good care. They told us they were aware of the complaints system. They also said they would be happy to raise any concerns they had with the staff and would be confident these would be listened to and acted upon.

However we found processes to keep people safe requires improvement. For example, some staff personnel files did not contain the person’s application form or references. There was no evidence to show all staff had been checked with the Disclosure and Barring Service (DBS) before they started work at the home. This breached Regulation 21 of The Health and Social Care Act 2008 (Requirements relating to workers) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

The home had not carried out a mental capacity assessments to determine if people had the capacity to give consent themselves. We also saw the home had made Best Interest decisions for someone without assessing their mental capacity. This meant the home had not acted in accordance within the requirements of the Mental Capacity Act 2005. This breached Regulation 18 (Consent to care and treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 210. You can see what action we told the provider to take at the back of the full version of the report.

On the day of the inspection there were eleven people living at the home. We saw people looked well cared for. We saw staff speaking in a caring and respectful manner to people who lived in the home. Staff demonstrated that they knew people’s individual characters, likes and dislikes.

People told us they enjoyed the food and we observed people were offered choice and supported in accessing food and drink independently

People said they received appropriate healthcare supported when required. For example people said “The GP, district nurse and anyone else visits whenever they are needed.”

People’s care plans and risk assessments were person centred. They were reviewed on a regular basis to make sure they provided accurate and up to date information.

All the staff we spoke with were aware of signs and symptoms which may indicate people were possibly being abused and the action they needed to take.

There was an effective quality assurance monitoring system in place which quickly identified any shortfalls in the service and there were systems in place for staff to learn from any accident, incidents or complaints received.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.