- Care home
Primrose House
We served a warning notice on Primrose House Ltd on 23 September 2026 for failure to meet the regulations related to having effective governance and oversight of the service.
Assessment report published 6 November 2026
Contents
Ratings
Our view of the service
Date of Inspection: 11 August to 11 September 2026. Primrose House is a care home providing personal and nursing care for up to 65 people. The service provides support to older people, some of whom were living with dementia and people with an enduring mental health condition. At the time of our inspection there were 44 people using the service.
We completed the assessment because of concerns being raised about the operation of the service, including safeguarding concerns and concerns about medicines management.
In August 2025, a new manager had come into post, and they were registered in May 2026 but cancelled their registration in July 2026. The deputy manager then oversaw the service until a replacement was identified. Between our first visit in August and final visit in September 2026, 3 managers had been in post. Two applied for registered manager status but subsequently left the service. On 11 September 2026, the current manager told us they intended to apply for registration and remain in post until a permanent manager was appointed. We had not been notified of any of these management changes.
In late 2024 a new director and their management team took over the operation of Primrose House Limited. They appointed a local regional management team to oversee the service. Since the last inspection there have been various changes to this team, including 3 changes to the provider representative. At the beginning of September 2026 most of the current provider representative and the regional management team left.
During our visits we found there was minimal regional team support, and it took several weeks to get the information we requested. The team had been unable to provide information to support the providers assertion that concerns had been identified prior to May 2026 and action had been taken. We found limited evidence to show the provider had been proactively overseeing the service. We were also made aware the provider had asked staff to provide us with incorrect information.
We identified widespread concerns about the quality, safety and consistency of care people received. Governance and oversight arrangements had not been effective in identifying and addressing risks. Concerns were identified in relation to medicines management, staffing levels, care planning, consent processes, nutrition and hydration, safeguarding oversight and the management of risk. Work was needed to ensure the building was in good repair and safe. Records were not always accurate, complete or sufficiently personalised, and people were not always involved in decisions affecting their care and support. We also found people were not always consulted appropriately when significant changes, including room and floor moves, were made.
The new manager and deputy manager were working to make improvements to the service. During the inspection improvements were made to the quantity and quality of the food, staffing levels, care records and medication management.
We found breaches of regulations relating to safe care and treatment, good governance, staffing, and person-centred care. We also identified concerns regarding notification requirements under registration regulations. Whistleblowing information received during the assessment raised further concerns regarding governance, transparency and the accuracy of information provided to regulators and commissioners.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations have been concluded, if the action has been taken forward. We have asked the provider to submit an action plan setting out how they will make and sustain the required improvements. We will continue to monitor the service closely and take further regulatory action where necessary.
People's experience of this service
The provider sent us survey information which contained lots of positive feedback about the service, alongside some concerns and areas for action. We considered this information together with feedback obtained directly from people, relatives and visiting professionals, which showed people's experiences of the service were mixed and more people had concerns than were happy with the service.
People and relatives described staff as generally kind, caring and respectful but felt this was not consistent. They generally felt safe, but they and their relatives raised concerns about staffing levels, continuity of care and delays in receiving support. A person said, “It’s alright but short-staffed.” Another person said, “Nothing wrong with the staff, good people, but not a lot of staff about.”
People found there was limited access to activities, the community and opportunities to develop their independence. A person said, “Staff treat me like a child, as if I don’t have a mind of my own.” We used structured observation to understand the experiences of people who could not easily tell us about their care. Albeit when present staff worked with people in a kind and sensitive manner there was often an absence of staff. On the top floor, we observed people were watching television and remained in the same seats from the beginning of the morning until the late afternoon. We did not observe an organised activity taking place in that lounge during this period.
People and relatives also described inconsistent experiences of personal care, communication, medicines and support when people’s needs changed. People, relatives and staff remained positive about the deputy manager’s management style and felt they had ensured improvements were made. A relative said, “[Deputy manager] is brilliant and has made sure staff look after [person’s name] really well.”
People’s views of the quality of food were mixed with some people describing it as ‘horrible’ and ‘it is not good’, whilst other people found it was ‘okay’. We observed the dining room experience throughout the service and found this varied. Also, we noticed there was limited choice and at times nothing, but meat and vegetables served. During the inspection a permanent chef was employed, a better menu created and better method of obtaining food stock put in place.
People had opportunities to raise concerns through meetings, complaints processes and access to advocacy. Some feedback resulted in practical changes, but several people and relatives felt concerns were not always heard or acted on. These people did not feel complaints or requests were responded to. People told us they had stopped complaining about the food because “everything falls on deaf ears.” A person said, “Sometimes there is no one to complain to, so I just make do.” Since starting at the service the new manager had been contacting relatives and started to complete reviews of care plans with them and their loved ones.