Date of assessment: 19 February to 6 March 2026. Primrose Healthcare Services Ltd is a domiciliary care agency providing personal care for people in their own homes. At the time of our assessment, 50 people using the service were in receipt of the regulated activity of personal care. This is a service used by autistic people or people with a learning disability but is not registered as a specialist service. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the service was working in line with this guidance. Staff were aware of their responsibility to safeguard people from the risk of harm and abuse, and the provider ensured any incidents were learnt from to prevent reoccurrence. Risk assessments and care plans were in place to inform staff of people’s health conditions, care needs and the environment they would be providing care in. These were updated on a regular basis to ensure information about people was up to date. There were appropriate numbers of safely recruited and knowledgeable staff, who were proud of the care they delivered to people. Staff encouraged people to remain as healthy and independent as possible and respected their rights under the Mental Capacity Act 2005. Staff felt the management team were approachable but knew how to whistle blow to external authorities should the need arise. Regular quality audits were completed to identify any shortfalls so these could be resolved. There were close working partnerships with external professionals in order to provide holistic care to people. The registered manager sought to gather feedback from people and staff on regular occasions, and rectified any concerns raised in a timely manner.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-5252867981.
This focused inspection of Primrose Healthcare Services Limited found the service to be Good in both Safe and Well-led, confirming that the previous breach of Regulation 17 had been remedied. Minor issues remained around late-call notification and keeping the electronic recording system fully up to date.
Concerns (3)
minorMissed or late visits: “I have had them turn up a lot later than expected, they mostly let me know but a few times they haven't”
minorRecord keeping: “the registered manager needed to ensure the system was kept up to date”
minorGovernance: “a recent recruitment audit had been completed and it had been identified that files did not contain all appropriate documentation”
Strengths
· Risks to people were assessed and monitored with clear care plan instructions for staff
· Electronic medicines administration records (EMARs) ensured people received appropriate medicines at correct times
· Staff wore full PPE and followed good infection prevention and control practices in people's homes
· Staff received safeguarding training and the registered manager served as safeguarding lead
· Accidents and incidents were reviewed and outcomes shared with staff to promote learning
Primrose Healthcare Services received an overall Good rating at its first inspection, with four of five key questions rated Good and strong feedback from people and relatives about caring, safe and effective care. Well-Led was rated Requires Improvement due to a breach of Regulation 17, as one registered manager was not involved in day-to-day operations, a family member's employment was not disclosed transparently, and care plan and staffing records were insufficiently detailed.
Concerns (4)
criticalGovernance: “an accurate record was not being kept of all persons employed for the service and records were not always detailed around the needs of people this is a breach of regulation 17”
criticalLeadership: “the registered managers were unable to work well together. One of the registered managers was not involved in the day to day running of the service”
moderateRecord keeping: “there was insufficient information in care plans on what these meant to people. We also found that the handwriting in the daily notes was not always easy to read.”
minorCare planning: “there were care plans that required more detail on people's backgrounds”
Strengths
· People felt safe with care staff and medicines were managed safely with appropriate MAR chart processes
· Staff received thorough induction, training including the Care Certificate, and regular supervision and competency checks
· People and relatives were very positive about the caring attitude of staff, describing them as kind, considerate and dignified
· End of life care was planned around people's wishes and end of life training had been booked with Princess Alice Hospice
· Robust risk assessments were individualised and provided clear guidance for staff on managing identified risks
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Good
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and control; End of life care and supportGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
well-led: Continuous learning and improving care; Working in partnership with othersGood
well-led: Planning and promoting person-centred, high-quality care and support; duty of candourGood