Primley Court is a large service set over two sites, providing nursing care for up to 80 people. The Court (New Wing and Old Wing) can accommodate and provide nursing and personal care for up to 51 people. The View is also part of Primley Court. This building is further up the road, it is not attached to The Court and provides care for up to 29 people. There were 46 people living at The Court and 24 people living at the view at the time of the inspection.

The service provides care for older people, many who have complex health needs and are living with dementia or a cognitive impairment. Some people required a high level of staff supervision (one to one care) and support to promote their independence and safety.

This inspection took place on 25, 26 and 27 July 2018. The first day of the inspection was unannounced. At the last inspection on 5 and 7 July 2017, the service was rated as Requires Improvement as we found issues related to the environment, infection control. The governance procedures in place at the time of that inspection had not recognised this. In line with our enforcement policy we took action to impose a positive condition on the provider's registration, which meant on a monthly basis they were required to audit the cleanliness and standard of the environment and equipment and send us a report on actions arising from the audit. The provider took action and at this inspection we found there had been positive changes to ensure the service had improved from “Requires Improvement” to “Good”.

Why the service is rated as Good:

People were protected from the risk of infection. In the July 2018 survey 91% of people said the home was clean and hygienic. One person told us, “Always hoovered and spring cleaned thoroughly, she gets rid of all the spiders.” Relatives shared, “You don’t smell any kind of odour”; “Room is always pristine clean”; “Mum’s room is spotless, and is her personal hygiene and clothing” and “My husband’s room is ultra clean – it’s spotless.” Staff confirmed they knew when to use protective equipment such as gloves and aprons to help reduce the likelihood of cross infection. Handwashing posters in bathrooms reminded people of the importance of good hand hygiene. Infection control training and food hygiene training was in place for staff. A laundress was employed to undertake laundry duties such as people’s personal items, and an external contractor undertook the linen laundry. Bedrooms were being refurbished with many having furniture, furnishings and carpets replaced to support cleanliness, for example carpeted areas had been changed to flooring. We visited all areas of the service, checked many of the bedrooms at both locations and found all areas smelled as clean and fresh as possible. A new environmental audit continued to monitor the cleanliness of the service and equipment.

The service was very well led by the registered manager and provider and supported by a dedicated team. There were quality assurance systems in place to help assess the ongoing quality of the service, and to help identify any areas which might require improvement. Complaints and incidents were learned from to ensure improvement. The registered manager and provider promoted the ethos of honesty and admitted when things had gone wrong. The service kept abreast of changes to maintain quality care.

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.

People and their relatives told us staff were dedicated, caring and kind. One person told us, “Staff are polite and courteous, super-duper!” and “They sit and talk and sometimes I have to say I have things to do! It is lovely here; I am interested in all o

This inspection was unannounced on the first day and took place on 5 and 10 June 2017.

Primley Court is a large service set over two sites, providing care for up to 80 people. The Court (New Wing and Old Wing) can accommodate and provide nursing and personal care for up to 51 people. The View is also part of Primley Court. This building is up the road and not attached to The Court and provides care for up to 29 people. There were 48 people living at The Court and 18 people living at The View at the time of the inspection.

The service provides care for older people, mainly people who have more complex needs and are living with dementia or a cognitive impairment. The service is part of a family run group of four other homes in the South West, two specialising in mental health care. Many people are physically fit but the nature of their condition may require a degree of staff supervision and support to maintain their safety, promote independence and well being. Other people were at the end stage of their dementia and less mobile and responded at varying degrees to sensory stimulation and one to one engagement. For example, one person with limited focus or verbal communication had tea and biscuits with their relative as staff knew this made them more receptive to their loved one’s visit.

People had their needs met. However, during our inspection we found a breach of regulation relating to some issues relating to the environment and infection control such as a dirty kitchenette and fridge on the New Wing, dirty mobility aid equipment and a poor standard of cleanliness of furniture in one room in particular.

There is a registered manager who is responsible for the home. 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 and associated Regulations about how the service is run.

On the day of the inspection people were going about their day as they wished. On the Old Wing there were two lounge/diners, one upstairs and one downstairs and people were sitting relaxing or mobilising freely with discreet staff supervision at all times to ensure they were safe but remained as independent as possible. Staff were very visible and allocated to manage certain areas and named individuals at higher risk. Staff were vigilant in monitoring people’s body language to help them ascertain what they needed, such as company, food and drink or support with pain or anxiety. There was a calm and relaxed atmosphere on the Old Wing where the communal areas were smaller. For example, although the four people in the upstairs Old Wing lounge had very limited verbal communication, staff were always present and engaging with people, enabling one person who liked to constantly mobilise to do so freely, and reassuring another person who had little spacial awareness to move up and down off the chair safely which they liked to do. Staff sat with another person who made regular vocal sounds reassuring them when they recognised the sounds changed, indicating possible anxiety. People appeared comfortable with the staff who were knowledgeable about their individual needs.

The New Wing at The Court was a purpose built extension comprised of a large communal space, divided into an open plan area and dining area leading to a kitchenette. Seating around the large windows and space led into a smaller seating area and cinema/TV room. There was a quiet seating area off the corridor where people were listening to music or napping. The majority, (26 of the 29) people living with dementia on the New Wing were independently mobile with limited verbal communication but displayed frequent vocal noises. In response to clear risk assessments, staff were allocated to discreetly supervise and provide care and support to small groups of 3 to 5 people or on a one

Primley Court provides accommodation and personal care for up to 80 people. Of these, 59 beds meet the needs of people living with dementia or mental health needs and 21 beds for people that require nursing. Primley Court is divided up in to two separate units, the Court Unit and the View Unit. The Court Unit has 51 beds with a further 29 beds at the View Unit. Most of the people who live at the home are older people with dementia. Some people may have complex needs or behaviours that challenge. At the time of our inspection there were 51 people living at the Court Unit and 26 people living at the View Unit.

The home had a 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 and associated Regulations about how the service is run.

During our previous inspection on 27 April 2015, we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The home was rated as 'Requires Improvement'. At this inspection we found some improvements had been made. There had been financial investment in the environment and improvements had been made around safety and auditing such as the medicine systems and processes. The home had implemented an electronic care planning system that had enabled care planning to be more effective and individualised. Primley Court’s ethos was to enhance the quality of life of residents by providing a home for people that had the flexibility to adapt to the needs of individuals. Throughout the inspection we saw they were continually working to improve the service provided to ensure that people who lived at the home were content with the care they received.

However, we found there were still some aspects of the service that needed improvement. Although the service responded to concerns raised with them, the governance systems in place were not yet established or operating sufficiently robustly to always identify and address improvements that were needed, in a timely way.

People were not provided with consistently kind and compassionate support. Although some staff were kind and respected people’s privacy and dignity, we observed this was not always the case. Some staff were rushed in their interactions with people and we saw that people were not always spoken about in a respectful manner. We also saw some good examples of practice such as staff comforting people by putting their arm around them or holding their hand.

Sufficient action had not been taken to ensure the environment was safe and suitable for people. For example, in the View Unit we saw some windows did not have window restrictors and chemicals were left in an unlocked room.

The Court Unit’s ‘new wing’ presented a difficult environment for people to feel safe or experience a homely living environment as the room was noisy and busy. The Court Unit did however, have a small quiet room with a more peaceful environment, and two smaller units with lounge areas for people to use.

The View Unit had an area designed for people living with dementia with a homely feeling lounge and comfortable chairs.

People living at Primley Court can only access the garden from the ‘new wing’ of the Court Unit. People living in the View Unit and older side of the Court Unit had no access to outside space.

The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff. Staff were suitably trained and training sessions were planned for any due or overdue refresher training. Staff received regular supervisions and appraisals.

Some risk assessment and management plans included guidance for staff to enable them to support people with behaviours that might present risks to themselves or others. However, some of these nee

This inspection was unannounced and took place on 27 April 2015.

Primley Court is a care home with nursing, registered to provide care for up to 52 people. The home provides care for older people living with dementia or mental health needs. At the time of the inspection we found that the building was undergoing changes to make the service more in line with good practice in dementia care. This included changes to provide smaller units where up to 12 people could live in a smaller group in more homely surroundings, and an internal and external refurbishment of the property.

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.

People were not always being protected from risks associated with the premises. We found that some areas of the building required attention to furnishings, décor, cleanliness and odour control, and that risk assessments did not fully protect people from risks associated with windows and glazed doors. We have made a recommendation in relation to the management of laundry services.

People were not protected against the risks associated with medicines, as some prescribed creams were being used for people for whom they were not prescribed.

People were not being protected by the home's recruitment processes, as the home did not have a proper recorded system in place to assess the risks presented by staff who may have a pre-existing criminal conviction. The systems for requesting references was not robust enough to protect people.

People did not always receive meals and fluids in a timely way. We saw that some people waited a long time between getting up and having their breakfast.

People did not always receive the care identified in their care plan, and some care plans were not detailed enough for staff to identify the care people needed.

People benefitted from some activities on offer. However not all activities were appropriate for people's needs or abilities. We made a recommendation in relation to activities suitable for people living with dementia.

People were being protected from abuse. Staff had received training in what to do to raise concerns over abuse or abusive practices, including information about external agencies to contact.

There were enough staff on duty to support people, and staff had the skills and knowledge to support people with their care. Staff understood people’s rights under the Mental Capacity Act 2005 and in relation to depriving people of their liberty.

People were supported to eat a nutritious diet, and had access to healthcare services that met their needs.

Staff demonstrated a caring attitude towards the people they were supporting. Some information was available around the home to support people orientate themselves but this was due to be increased following the changes planned to the environment. Staff communicated effectively with people and knew them well.

People benefitted from clearly understood complaints procedures which were on display in the home.

Quality assurance systems were in place and learning took place from incidents to improve safety and quality.

Records were being well maintained and were updated regularly.

We found a number of breaches of regulations and you can see what action we told the provider to take at the back of the full version of the report.

We inspected Primley Court as a part of our scheduled inspection programme. We had also received some concerns about the lack of comfort and homeliness, and the responsiveness and communication of staff.

The inspection team who carried out this inspection consisted of an adult social care inspector and an expert by experience. During the inspection the team worked together to answer five key questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

As part of this inspection we spoke with 10 people who use the service, five visitors, the Registered Manager, representatives of the provider, four care staff and three nursing staff. We also reviewed records relating to the management of the home which included nine care plans and observed the care and support people received.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

We saw that staff spoke of people with a caring attitude and appropriate language. One staff member we spoke with told us about how they tailored care to meet people’s individual needs. They said that if the person they were supporting was “not used to having a shower and are frightened by them, we do the bathing in a way that is comfortable for them. Each individual is different; they need reassurance and to be talked to differently.” This told us staff treated people as individuals and thought about how to provide care to them in a person centred way.

We saw the home and family members of people had worked together to ensure potential distress could be anticipated and alleviated for people with advanced dementia. For example we saw copies of a letter in one person’s file to give to the person from their relative in case they became distressed or agitated if their family member was not able to visit. This was used to help reduce the person’s distress and reassure them as to why their relative was not there.

We saw staff supporting people throughout the day. The interactions we saw were kind and respectful. We saw a member of staff supporting a person who was sitting bent over in their chair with their head in their hands. We saw the staff member came down to the person’s eye level and touched their hand. We saw they spoke gently to the person, starting the conversation by using the person’s name and helped them sit upright. They said “Are you a little bit tired. Do you want to sit somewhere cooler? I’ll give you a nice cold drink”. We saw the person responded well and stood up with the staff member to find somewhere else to sit. They were given a cool drink.

However we also saw a few occasions when staff missed opportunities to engage with people or spoke about them without including them in the conversation. This could make people feel undermined or excluded.

Is the service responsive?

We saw the home responded to people’s changing needs. A visitor told us “They are very receptive to (name's) needs because he isn’t a people person. There is sensitivity to the fact that he likes to be in his room in private.”

Prior to the inspection we had received some information about the lack of homeliness and comfort at the home and problems with the temperature levels in the conservatory. On the day of our visit this area was very uncomfortable, being hot, bright and noisy. We saw that these comments had been raised along with concerns about the main lounge/conservatory area in a recent relative’s forum. A relative told us “It’s institutionalised in the lounge. It needs more homely furniture. No pictures, no curtains. In winter it is very plain. We have given up saying it”.

We saw that the provider was taking action. For example we saw evidence that showed us that air conditioning was being installed the week following the inspection. The provider told us that film was to be fitted to the roof in the conservatory to reduce the brightness and glare in this area. A study had been carried out in conjunction with the local university and older person’s mental health team, part of which looked at the impact of the environment on people. We were told further action would be taken to improve comfort in this area.

Is the service safe?

We saw that there were assessments of risk undertaken of the environment, for individual people and for staff safe working practices. These had been regularly reviewed and action taken where necessary to reduce risks.

We saw there were enough staff on duty with the right level of skills to support people. Registered nurses were on duty at all times.

CQC is responsible for monitoring the deprivation of liberty safeguards which applies to care homes. No-one at the home was subject to an authorisation by the Court of Protection, although the home manager had made applications for authorisations in the past. The home manager was aware that following a recent Supreme Court judgement, applications would need to be made to ensure that where people had been deprived of their liberty, through for example locked doors, this was lawful. The manager had taken steps to speak with the local care trust about what actions to take and to prioritise applications. This told us that the provider understood the actions they needed to take to ensure that people’s rights were protected and that where people were being deprived of their liberty this was in accordance with the protection of legislation.

Is the service effective?

We saw effective systems for communication within the home. We saw the way information was handed over to staff between shifts and how staff duties were allocated each day. People who needed 1:1 support had this clearly identified and any risks were highlighted.

We saw the plans had been effective in supporting people. For example we saw one person needed their food provided at a soft consistency. A nutritional risk assessment indicated they had been at risk of poor nutrition. We saw that their care plan indicated they ate their meal very slowly with staff support, and that staff needed to help the person focus on the meal even though it took a long time to help them eat at their own pace. We saw that by staff following the care plan the person’s weight had increased and they were eating well with staff support.

Is the service well led?

The manager of the home was experienced and knowledgeable. Staff had a clear understanding of their role and lines of authority within the home. Discussions indicated they had a shared ethos and understood people’s needs well. Staff told us they enjoyed working at the home.

We saw there were clear quality assurance systems in place. Relatives and visitors told us they were asked for their feedback about the home.

Further work was being undertaken to develop the home. For example we saw they had been involved in initiatives with the local university and older people’s mental health team. Staff had developed their individual skills to become champions in specific areas such as end of life care. This had involved attending training and regular meetings outside of the home to share good practice.

At this inspection we followed up on concerns we had at our inspection on 11 September 2012. Concerns included incorrect use of the Mental Capacity Act (2005). People not having care needs met effectively or safely. Infection control concerns. Not supporting staff with supervision or appraisal. Quality assurance systems ineffective and the home had not notified us of incidents.

At our inspection on 10 April 2013 we found that the home had made significant improvements.

We toured the home looking at six bedrooms, two toilets, two bathrooms and three lounge and dining areas. We found that the home was clean and tidy.

We saw that people's choices about their care were considered. This was supported by what we observed and what we saw in care records. We saw staff respected people's privacy and dignity. We saw staff respected equality and diversity.

We saw from care records that staff were completing mental capacity assessments for people to ascertain consent for day to day personal care and for more significant decisions.

We observed activities going on through out the inspection. People were smiling, laughing, singing and dancing. All interactions that we observed between staff and people were positive.

Staff told us that they felt supported by the manager. We saw that staff received training and regular supervision.

The home had effective systems in place for monitoring the quality of the service. The home had notified us of incidents when appropriate.

On 25 October we found that Primley Court was not compliant with a Warning Notice that we issued against the home following our inspection on 11 September 2012. A Warning Notice is one form of enforcement action that we take against providers where we find that there are major concerns. We had major concerns about the home in relation to safeguarding adults. At our inspection on 25 October 2012 we found that the home was in the early stages of making changes.

At the inspection on 8 January 2013 we looked at the care records of people who were referred to in the Warning Notice. We looked at all documents within the care records of four people who lived at the home. This included care plans, risk assessments and daily care records. We looked at incident report records and audits.

We found that people were protected from physical aggression from other individuals who lived at the home, because the home had an appropriate system in place to manage acts of violence and aggression. The home had implemented a system to monitor incidents of violence and aggression. We found that the home completed incident forms and identified patterns of aggression.

There was evidence that the manager offered staff support and guidance through immediate supervision. We saw that the home received support from external agencies which the manager and provider confirmed had been helpful. We found that the home was now compliant with the Warning Notice.

Because of the complexities of people's illnesses, most people at the home were unable to express their views. Observation was used to assess the wellbeing and happiness of people, as well as speaking with them. We looked at the care records of people who were referred to in the Warning Notice. We found that the home was starting to improve in some areas however we found that they were not yet compliant with the Warning Notice.

We looked at all documents within the care records of three people who use the service. This included looking at care plans, risk assessments and daily care records. We looked at incident report records in relation to an incident of physical abuse from one service user to another service user.

People were still at risk of physical aggression from other service users because the home did not have an appropriate system in place to manage acts of violence and aggression. We found that one person had been physically assaulted by another service user and that the follow up action was not complete.

Because of the complexities of people's illnesses, most people at the home were unable to express their views. Observation was used to assess the wellbeing and happiness of people, as well as speaking with them. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care used to understand experiences of people unable to talk with us. We spent sixty minutes closely observing four people. We spoke with eight people that lived at the home, two of their relatives and nine staff. We looked at seven care records and seventeen care plans.

We visited six bedrooms, three lounge diners, four toilets and two bathrooms and saw that some of the facilities were not clean.

People who use the service were not fully involved in decisions made about their care and treatment. We found that mental capacity assessments had not been completed. People were at risk of physical aggression from other service users because the home did not have an appropriate system in place to manage acts of violence and aggression. People’s dignity was not always protected and on the day of this inspection people were not offered choice.