Primrose House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

We found the provider was in breach of the legal regulations relating to person-centred care, and good governance.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did make sure people’s health, care, wellbeing and communication needs were effectively assessed and reviewed with them. People underwent assessments before moving into the service and reviews were completed during their stay. However, some relatives also raised concerns about people’s changing needs, not always being recognised or addressed promptly. Care records were not always accurate, complete or sufficiently personalised to guide staff on how to meet people's individual needs. A lot of pre-generated templates were in place, which provided lots of information but often this was not relevant to the person or if it was not tailored to show how to implement the guidance with the person. We noted care records had been altered some weeks before the inspection to provide less information. The provider’s audits had not identified this discrepancy.From September 2026 the new manager and deputy manager recognised these shortfalls and had started work to strengthen the care records.

The provider did not make sure people received care and treatment in line with current evidence-based guidance and best practice. Staff supported people living with a range of complex health conditions including epilepsy, diabetes, dysphagia, PEG feeding requirements and mental health needs. From the records the provider supplied 3 weeks after we commenced the inspection positive practices were indicated in risk assessments and staff learning records. These documents referenced the importance of seizure, and choking risks management, the need for positive behaviour support plans to be in place and used, plus the expectation staff escalated healthcare concerns. Incident reviews we were sent demonstrated that staff reflected on events and reinforced learning through supervision and team meetings. However, within the service we had not found any of these documents and staff had confirmed whilst the previous manager was in post incidents had not been reviewed and staff had not looked at any lessons they could learn.

We found best practice guidance was not always followed consistently. Concerns had been identified around staff not seeking medical advice in a timely manner, poor medicine and them not understanding how to provide a rehabilitation service. Visiting healthcare professionals reported concerns regarding the management of PEG equipment, hydration monitoring and the implementation of professional recommendations. A person said, “I’m allergic to the soaps they used, but staff won’t use different products.” Complaint investigations identified delays in implementing clinical advice, inconsistent application of care plans and occasions where professional recommendations were not acted on promptly.

The provider did not always make sure staff, teams and partner organisations worked together effectively to achieve good outcomes for people. The records supplied by the provider showed the service worked with a range of healthcare professionals including district nurses, rapid response teams, GPs and community services. Staff meetings highlighted learning around multidisciplinary communication and information sharing. There was evidence of referrals being made and professional advice being sought when concerns about people's health were identified. However, complaints, professional feedback and inspection findings identified ongoing concerns regarding communication and collaborative working. Professionals reported difficulty obtaining information, delays in acting on recommendations and occasions where communication arrangements were ineffective. Relatives also described inconsistent communication and uncertainty regarding changes in management and care arrangements.

Although staff demonstrated a good understanding of people's individual needs, leadership instability and high staff turnover affected continuity and consistency. Several relatives described frequent management changes and concerns about communication around room moves and care decisions. One relative told us, “The only complaint I have is the constant turnover of the home manager.” The new manager had recognised these concerns and introduced actions aimed at strengthening communication, improving handovers and reinforcing expectations around professional working relationships. However, improvements were not yet fully implemented or embedded.

The provider did not always make sure people were supported to maintain and improve their health and wellbeing. The provider supplied documents to show centrally they monitored nutritional risk through MUST assessments, weight monitoring and person-centred nutritional plans. These showed interventions for people at risk of malnutrition were identified those requiring enhanced support were referred to dietitians. However, inspection findings identified concerns regarding nutrition, hydration and healthcare oversight. Whilst at the service the staff had not been aware of these documents, or how to produce them or been able to show how they ensured people were supported to maintain their weight.

Care records did not always demonstrate effective monitoring of nutritional needs and there was evidence that some professional recommendations relating to nutrition, hydration and clinical care had not always been implemented consistently. Concerns had been raised regarding food quality, weight loss and adapted diets. Complaint reviews and professional feedback also highlighted delays in responding to changing healthcare needs. We observed mealtime experiences and found portion sizes were small. On some units, vegetables were not served with the main meal and they struggled to provide appertising vegetarian meals. Food stocks were limited and the catering staff did not have the appropriate equipment for making the adapted diets. We discussed this with the provider who immediately changed the food ordering system and ordered equipment to blend food.

The provider did not always effectively monitor outcomes for people or use information consistently to drive improvement. The provider supplied documents to show they had systems to review incidents, complaints, audits and feedback. The monthly incident audits demonstrated trend analysis, learning and action planning. Staff meetings included discussion of incidents, safeguarding concerns, complaints and lessons learned. Environmental checks, maintenance audits and resident feedback processes also evidenced attempts to monitor service quality and safety. However, within the service these had not been available and staff confirmed audits had not been completed during the time the previous manager was in post.

Despite these systems, we identified significant gaps in governance and oversight. Concerns regarding medicines management, staffing, care planning, consent processes and communication had not always been identified or acted upon in a timely manner. The previous management arrangements had failed to maintain effective oversight and learning was not consistently embedded across the service. Although more recent records demonstrated increasing audit activity, reflective learning and action planning, improvements were not yet fully established or evidenced in practice.

The provider did not always make sure consent to care and treatment was obtained and recorded in line with legislation and guidance. Staff sought people's consent during day-to-day interactions and observations showed staff routinely offered choice and involved people in decisions about their care and support. Risk assessments also reflected a least restrictive approach and recognised people's rights, choice and capacity where appropriate. However, concerns were identified regarding how capacity assessments and best-interest decisions were completed and recorded. Assessments of capacity were not always in place for restrictions people experienced and records often focused primarily on DoLS applications. On occasions when significant decisions affecting people, including environmental and room changes, had not consistently been supported by robust consultation, capacity assessments or documented best-interest decision-making. Although the new manager was making improvements, systems had not consistently ensured consent and capacity requirements were fully met.