A care home that’s been praised for its “positive, kind and caring culture” has been told it requires improvement by the care quality commission.

Inspectors visited Primrose Court on Normanby Road on September 12. They found records and care plans for residents were not always up to date, with some including the wrong gender and name, and checks after falls were not properly documented.

However, the CQC report does state that staff are kind and caring and treat people with respect. The home can care for up to 20 elderly people living with dementia – at the time of the inspection, there were 15 people using the service.

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The last inspection took place in May 2021 when it was rated as good, however, prior to this, it was rated as inadequate, due to a lack of adequately trained and competent staff and delays in reporting safeguarding concerns.

The report says records around risks to people were not always robust. The review states: “One person’s care plan had not been updated when their needs had significantly changed.

“Some of the up-to-date information was contained within monthly reviews of the care plan, but the care plans themselves did not reflect the support this person required.

“This person’s evacuation plan in the event of a fire was out of date and not suitable for the person’s needs. This person required a high-calorie diet but was not on the corresponding kitchen list.”

End-of-life care plans were not in place in the sample of care plans that were reviewed by the inspector. However, the manager assured the CQC that he was in the process of finding out and recording people’s wishes. Residents and their families are consulted when care plans change, however some records are not accurate and included the wrong gender, and on occasion, even the wrong name.

Another issue mentioned was staff not checking the water temperature in the shower or bath before the residents got in, though the maintenance person did regularly check how hot/cold the water is. It is also policy to carry out regular observations for 72 hours following a fall, though there was no documentation in place to record these checks – the manager has now implemented this.

Recruitment at the care home did not always follow expected practice. During the process, full employment histories were not taken and gaps in employment were not probed further – the manager has taken steps to address this and DBS checks were carried out.

However, it wasn’t all bad news at the home and three of the five areas inspected were rated as good. There are enough staff on duty to ensure that people are properly supported and the manager kept people safe from abuse.

Speaking about what they would do if they had safeguarding concerns one staff member said: “I would go straight to the manager. If I was still worried, I would go straight to CQC and the local authority.”

Residents and relatives both said that they were not worried about people’s safety. One person said: “Staff are nice, and I have no concerns at all.”

The report states that medicines are managed safely, the inspector was assured the provider was supporting people to minimise the spread of infection and lessons were learnt when things went wrong.

Residents were also supported to maintain a balanced diet and staff would sit with people who don’t eat very much to encourage them to have their meal. Staff also had the right skills and experience, one employee said they were “quite happy” with the training and didn’t feel there was anything missing from it.

The review states that staff treated people with kindness and the inspector saw caring interactions between staff and people. One relative said “staff are lovely, I can’t fault them”, while another added “staff are brilliant, supportive, and very caring.”

Care workers would also give residents choices and one family member noted that they helped people retain as much independence as possible. One relative described the atmosphere as “friendly, warm and caring” and another added, “the atmosphere is lovely, the carers are brilliant, I wouldn’t change anything.”

The provider had not received any recent complaints or concerns, while one relative said the registered manager was “really good”. A staff member added that he was “lovely and approachable, and always there if we need him.”

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