Primrose Hill Nursing Home

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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance at the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always demonstrate a consistent and shared culture across staff and leadership.

Staff feedback highlighted some concerns regarding the support, visibility and consistency of leadership. We identified inconsistencies in practice, in areas such as care planning and risk management, which showed that the provider’s values and approach were not always consistently applied across the service. This meant people did not always receive care that reflected the provider’s stated values in practice.

At the last inspection, we raised concerns about governance. At that time, a new registered manager was in post, and an action plan was implemented to drive improvements. However, at this inspection, we found that these systems had not resulted in sufficient or sustained improvements, and concerns remained.

One staff member described the culture as “mostly positive.” However, the registered manager was able to describe the values of the service, and staff reflected these, telling us they aimed to deliver care in line with these principles.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

The lack of effective systems and oversight of the care people received demonstrated that leadership and management were not consistently effective in ensuring good governance.

Feedback from staff indicated some concerns regarding management practices. One staff member told us, “I think management always have their favourites, rotas can be late, they should be 4 weekly, but it’s weekly.” This suggests that staff did not always feel management processes were fair or well organised.

However, the registered manager was able to describe their role and the values of the service, including promoting dignity and person‑centred care. Some staff also spoke positively about management and the workplace.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff reported that they generally felt able to raise concerns and communicate openly with colleagues. They described the environment as supportive, where issues could be discussed and help sought when needed.

A staff member said, “I know the whistleblowing policy and would go to head office if I had concerns about management themselves.”

A whistleblowing policy was in place, and staff confirmed they had access to it when required.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures were in place to support equality and prevent discrimination. Staff were aware of the importance of treating colleagues fairly and respectfully, and the registered manager described being mindful of staff needs and making reasonable adjustments where required.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At the last inspection on 26 August 2025, the provider was in breach of the regulation relating to good governance.

At this inspection, we found that care plans and risk assessments were not consistently accurate, up to date or reflective of people’s current needs. As a result, staff did not always have clear guidance to deliver safe and consistent care. In addition, concerns relating to medicines management had not been identified through the provider’s own systems. This showed that governance and monitoring systems were not always effective in identifying and addressing risks. These were the same concerns identified at the previous inspection, indicating that sufficient and sustained improvements had not been made.

The provider therefore remained in breach of the regulation relating to good governance.

However, the registered manager was open and responsive to feedback and had begun taking action to address the concerns identified during the inspection. We will review whether these improvements have been embedded and sustained at the next inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and leaders demonstrated an understanding of their responsibility to work in partnership with external agencies such as health care professionals to promote people’s safety and wellbeing.

The service worked collaboratively with the integrated care board (ICB) when concerns were identified. Information was shared appropriately, and leaders were open and transparent during safeguarding enquiries. This reflected effective partnership working, ensuring appropriate oversight and helping to protect people from harm.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice.

Effective systems were not in place to ensure consistent learning from incidents. This meant opportunities to learn from events and improve people’s care were sometimes missed.

The provider had not taken effective action to address all of the concerns identified at the previous inspection. As a result, we were not assured that learning and improvements had been fully embedded or sustained.

However, staff told us they were able to suggest improvements and work together as a team to make changes. The registered manager also shared plans for future improvements, including developing the outdoor gardening area. They described their intention to maintain positive working relationships with CQC and with external partners to support ongoing improvements for the benefit of people living at the service.