Primrose House

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.