Primrose House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At the last inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

We found the provider was in breach of the legal regulation relating to management and good governance.

This service scored 36 (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 not create a positive culture or a shared vision that ensured high-quality, person-centred care. Staff, relatives and external professionals described a significant deterioration in the operation of the service, and concerns raised about people's wellbeing had not resulted in meaningful or sustained improvements. Staff told us previous leaders were not visible, approachable or responsive to concerns and did not make them feel valued or supported. There was a high turnover of managers and staff, which contributed to instability and uncertainty across the service. People, relatives and staff consistently identified the deputy manager as a positive influence who demonstrated a person-centred approach and helped sustain some good practices despite wider leadership failures. However, this was insufficient to overcome the wider cultural concerns.

The provider could not demonstrate they were always capable of providing effective oversight of the service or ensuring people consistently received safe, high-quality care. The service experienced considerable instability in leadership, with multiple management changes over a short period and no registered manager in post at the time of the assessment. Staff, relatives and visiting professionals repeatedly described a lack of management visibility and oversight. Although the deputy manager was consistently praised by people, relatives and staff for being caring, approachable and committed to people's wellbeing, this individual was unable to provide sufficient oversight because of wider management arrangements. There was no evidence within the service to show the previous manager listened to concerns or acted effectively when issues were identified. Concerns relating to staffing, nutrition, medicines, care planning and safeguarding had persisted over time without adequate leadership intervention. While newly appointed leaders had begun implementing audits and improvement plans, these actions were too recent to demonstrate sustainable change.

The provider had not always developed a culture where people and staff felt able to speak up and share concerns. People and staff could access processes to raise concerns, and the provider sent in evidence they encouraged feedback through staff meetings, resident meetings and relatives' meetings. However, staff told us the previous managers had actively discouraged them from speaking up. They described how the previous manager had ‘just stayed in the office’ and if they raised concerns these were dismissed. People told us complaints were not always listened to and some had stopped raising concerns because they felt nothing would change. Relatives reported occasions where communication had been poor and concerns had not always been addressed effectively. While staff meeting minutes included discussion of safeguarding and whistleblowing responsibilities, we found safeguarding concerns, incidents and complaints were not always investigated thoroughly or used to drive improvement. Staff were reluctant to raise issues due to a lack of confidence in provider governance arrangements. As a result, systems to support speaking up were present but had not consistently resulted in people and staff feeling their concerns led to effective action.

The provider promoted equality, diversity and inclusion within the workforce and had implemented systems to support staff from diverse backgrounds. Staff completed equality and diversity training and leaders demonstrated an understanding of their responsibilities under equality legislation. The service employed a diverse workforce and had arrangements in place to support staff with protected characteristics, including pregnancy risk assessments, reasonable adjustments and access to support from line managers.

Governance and oversight systems were ineffective and had failed to identify, monitor and address significant risks to people. The provider had not ensured quality assurance systems were robust or effective. Multiple concerns had been raised by people, relatives, staff and professionals regarding medicines management, nutrition, staffing, communication, safeguarding and care delivery, yet limited action had been taken to bring about sustained improvement. Information requested by CQC was not provided within a timely manner, and regulators were not informed about significant changes to management arrangements. For example, during the inspection we were not informed of the 3 changes to the manager. Over the last year, the provider had not notified CQC of any of the changes to the manager. Also we have not always been notified about significant events such as the closure of the top floor, police involvement and some safeguarding concerns.

We found a lack of assurance that audits and action plans had been used effectively to improve outcomes for people. A range of concerns regarding governance arrangements, including allegations of falsified audits, and retrospective completion of records were raised. Records the provider sent us did not match what was found in the service and included items such as satisfaction surveys which reported everyone was happy but this was inconsistent with all the feedback we had received. Although the provider subsequently produced audits, governance reports and action plans which demonstrated some recent oversight activity, these were not reflective of the concerns identified and had not been in the service. Staff confirmed no audits had been completed over the last 6 months. The scale and significance of the concerns meant governance systems could not be relied upon to keep people safe.

Staff generally understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, partnership working was not always effective. Visiting professionals reported occasions when staff did not seek appropriate medical support promptly and concerns were raised regarding communication with external professionals. Regulators and commissioners were not always informed promptly about significant changes in leadership arrangements, such as repeated changes to the managers, and changes to the management team. The provider did not communicate with external professionals in a timely manner or share information when this was requested.

The provider did not focus effectively on continuous learning, innovation and improvement across the organisation or local system. They did not ensure learning from incidents, safeguarding concerns, complaints and professional feedback was consistently identified, shared and embedded into practice. The previous management arrangements had failed to identify and investigate incidents consistently. Staff, including the deputy manager, had not always been made aware of concerns about people’s care. There was no reliable evidence that lessons had been learned following serious incidents, accidents and safeguarding concerns, or that effective measures had been introduced to reduce the risk of recurrence. Safeguarding concerns and statutory notifications had also not always been raised promptly. The evidence reviewed did not demonstrate the provider encouraged creative ways of improving people’s experiences and outcomes or actively contributed to research and wider best practice.

Concerns about medicines, staffing, care planning, consent, nutrition, hydration and communication had not been identified or addressed effectively through the provider’s governance arrangements. Although the provider said from May 2025 consultants, audits and action plans had been used, records of these were not produced. We found minimal regional support and limited evidence of proactive provider oversight.

The provider later supplied incident audits and staff meeting records describing incident reviews, refresher training and lessons from complaints being shared with the staff. These included learning about fire safety, seizure management, medicines, eating and drinking, communication and community access. However, these records had not been available within the service during the assessment, and staff confirmed that audits and incident reviews had not been consistently completed under the previous management arrangements. The learning described in the later records was therefore not sufficiently reflected in people’s day-to-day experiences or embedded across the service.