Primrose House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At the last inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We found the provider was in breach of the legal regulations relating to medicines management, risk management, staffing and good governance.

This service scored 41 (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 had systems to review incidents and share learning, but these were not always effective in ensuring lessons were identified and embedded into practice. Staff meeting records and incident audits demonstrated examples of incident review, trend analysis and reflective learning. However, the previous management team had not consistently investigated incidents, shared learning with staff, or ensured safeguarding concerns, complaints and incidents resulted in meaningful improvements. This meant opportunities to reduce future risks were not always identified or acted upon.

There were systems to support people when accessing healthcare services and moving between services, but these were not always effective. Risk assessments included guidance for community access, healthcare escalation and supporting people with complex health needs. However, healthcare professionals reported staff had not always responded promptly when people's health deteriorated or sought appropriate medical intervention. In addition, not all people or relatives had been appropriately consulted when significant changes were made within the home, such as moving to different bedrooms and floor moves.

Staff understood their safeguarding responsibilities, and there were systems for raising safeguarding concerns. Staff meeting records demonstrated safeguarding, and whistleblowing responsibilities were regularly discussed. Safeguarding referrals had been submitted when incidents occurred. However, safeguarding incidents were not consistently investigated, lessons learned were not embedded, and notifications were not submitted appropriately. This showed safeguarding processes had not always been used effectively to protect people from the risk of harm.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Staff understood when Deprivation of Liberty Safeguards (DoLS) authorisations would need to be sought, and what to do if there were conditions imposed.

Staff knew people well and people told us they felt safe and supported. However, improvements were still required to ensure risk assessments fully reflected all known risks and clearly recorded actions staff should follow. Some risk assessments were not in place for significant issues such as risk of injury when off the unit, or risk of dehydration, risk associated with having items such as percutaneous endoscopic gastrostomy (PEGs) in place and managing distress behaviours. The new manager and deputy manager recognised these shortfalls and had started work to strengthen the risk assessments.

Following the inspection the provider supplied records to show work continued to be taken to improve risk management. By 3 September 2026, the new management team had completed a series of person-specific assessments addressing these areas. These records identified individual risks, triggers and actions for staff, including monitoring and escalation requirements, supervision when using tools or equipment, and arrangements if a person became separated from staff in the community. However, some of these provided generic guidance, which did not set who was qualified or competent to undertake tasks. Evidence from professionals and other records showed the documented controls and professional recommendations had not always been implemented consistently. We were therefore not fully assured that the improved risk-management documentation was reliably embedded in people’s day-to-day care.

The provider did not always maintain a safe environment. Although environmental audits demonstrated regular checks of equipment, water temperatures, window restrictors and safety systems, the inspection identified significant concerns regarding the premises. These included an electrical fire where evidence of completed remedial works had not been provided, concerns regarding large windows without appropriate protection, and poor maintenance in parts of the building. Also, in September 2026 a persistent malodour, had been noted and this led to the top floor being closed whilst repairs were made. Although the new manager took immediate action to rectify issues with the windows and confirm the safety of the electrical installation no information was supplied to show action had been taken to address this and the malodour.

On 2 November 2026 the provider supplied additional records to show physical safety measures were taken following the April electrical fire, domestic staff had completed extra cleaning and there was a single horizontal rail across a window. However, this information did not demonstrate the underlying is causing the malodour had been addressed. We also noted the rail across the window would not prevent someone falling through it.

Staffing levels did not always meet people's needs. Feedback from people, relatives and staff consistently referred to staffing shortages, high staff turnover and reliance on agency staff. On night shifts there was often 1 nurse responsible for multiple floors without additional support. On 1 unit, care staff numbers had been routinely increased by the use of the activity co-ordinator. This meant the staff member could do neither job to the best of their ability. Staff communication was poor and even when known events such as night staff needing to take over the care of someone at hospital no replacement staff were brought in. This meant staff at the home were left short. On 11 September 2026 the new manager stated on 9 September 2026 the staffing levels were increased to 12 staff during the day and 9 staff at night. This is yet to be demonstrated as sustained.

Recruitments practices met requirements. However, since January 2026 there had been a high turnover of staff, with 25 staff members leaving and therefore a reliance on agency staff for multiple roles per shift. Also there had been 3 changes of manager during the inspection and we only discovered these changes when visiting or contacting the service. The new manager had only been in post from 4 September and we were not assured this would be permanent.

The provider and staff gave us conflicting information about the number of staff who had left and therefore we were not assured the management team understood the volume of staff leaving or they explored why staff retention had deteriorated.

Infection prevention and control systems were in place, but these were not consistently effective. Environmental monitoring and safety audits included infection prevention measures, and people and relatives were provided with information about infection control expectations. However, the cleanliness of some areas of the service needed to be improved. Domestic staffing shortages had led to them not being able to ensure the deep cleaning tasks were routinely completed. Equipment such as soap and wipes had not always available and environmental issues had not been fully resolved. Since coming into post the new manager had been working with the domestic team to ensure the service was thoroughly cleaned.

Medicines were not managed safely as clear and consistent records were not always kept. There were gaps on the MAR where there was no staff signature or non-administration code. When counted, stock for 2 people did not balance with records. Some medicines were out of stock and could not be given as prescribed.

For creams applied by care staff; some guidance was missing, and records were not fully completed. Guidance for ‘when required’ medicines needed to have more person-centred information and include information on variable dose directions and linked if more than one medicine for a condition. Records need to show why given and whether effective. Information on how people took their medicines if given covertly was not sufficiently clear. Medicine information in some care plans was not updated when changes happened.

Medicinesstorage roomswere clean, tidy and well-organised. Comprehensive policies and procedures were in place to support the administration of medicines. The manager was aware of some of the issues relating to the management of medicines, however this was not reflected in audit scores.