Primrose Bank Care 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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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 a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider sought to share their vision of providing a compassionate and individualised service that celebrated people’s individuality. Staff told us they felt supported and involved in improving the service and they considered they worked well as a team. The registered manager supported staff to understand the aim of the service, which was to deliver good care which met people’s needs and promoted their rights.

Staff told us the registered manager spent time with people gaining their views and was committed to delivering the best service possible. This was echoed by relatives and people who used the service. Comments we received included, “I see her regularly; we have a good relationship” and “she does walk about and we talk and chat regularly.” Also, “You wouldn’t need the Care Quality Commission if all homes were run like that.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Relatives said the registered manager was approachable and sought to engage with them. They shared the registered manager was available if they needed to speak with them on an individual basis, and that group meetings were held to allow relatives and people to come together and share their experiences. One relative commented, “I see her all the time– she comes to me and has a word. She is very friendly and helpful.” People told us they knew the registered manager and they were able to speak with them if they wanted to do so. Staff told us they had meetings and discussions with the registered manager where they were able to seek clarity and bring ideas for consideration. A staff member commented, “[Management team] are open to ideas."

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

The provider supported a positive culture where people felt they could speak up and their voice would be heard. Staff told us they would enable people to raise concerns by sharing this with the registered manager. Staff were aware of their right to speak up and said they were confident the registered manager and provider would respond positively if they did so. One staff member commented, “I’ve got no qualms about going up to the office.”

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.

The provider had a supportive culture which valued staff. Staff told us they felt valued and were confident the registered manager and provider promoted inclusion and equity. Staff could give examples of how their individuality was recognised and their rights upheld. One staff member shared how they had needed extra support in an area of their work, this was provided.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Audit systems effectively drove improvement. Audits identified shortfalls and staff told us the outcomes of audits were shared with them so changes could be made. A variety of formal audits and informal checks were carried out and records showed conversations took place with staff to help improvements take place. A staff member commented, “[Management] are always trying to improve.” A relative commented, “They don’t sit on their laurels; they are constantly looking for ways to improve and seem to have improved immensely these last six months.”

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

The provider had adopted and joined an electronic shared care record system. This meant people who lived at the service had their information entered into a secure shared system which only health and social care professionals could access. This helped ensure information was accessible for health and social care professionals and promoted safer treatment, care continuity, person centred care and supported informed and timely health professional decisions. The registered manager said they had adopted this as they wanted to ensure information was shared seamlessly, securely and in a timely way so people could access the services they needed at a time they needed them. They went on to say that by joining the shared care record system, it supported effective clinical decision making and helped ensure people only had to share their information once. The registered manager gave examples of how this was having a positive impact on people’s lives. By reviewing the shared record system, the registered manager had identified that a person at the home was having a reoccurring health challenge and consequently was able to share this with the persons doctor for their consideration. In addition, the registered manager had been able to access electronic hospital discharge records when paper records were not available and had been able to adjust care accordingly. This meant information gained was supporting seamless and effective care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider sought to improve the service provided. The provider had invested in a new care planning system which supported efficient and effective care planning and review. The care planning system could be altered to make care planning person centred and also allowed relatives to view records of their family members care. The registered manager was in the process of transferring existing care records onto the new system and this had been effectively planned. Staff we spoke with told us they had received training and support in the new system and they were confident in its use. In addition, there was a period of time where access to the previous system was still available so any initial challenges could be addressed.

The provider was in the process of introducing a new secure electronic activities system. This would allow photos of people to be entered daily on the system, with written information of how the person had enjoyed the activity and the outcome of the activity. With permission, this could be accessed by relatives who would be able to see their family members activities and the impact these had on them. The registered manager said she hoped this would offer reassurance and comfort to relatives and help them maintain knowledge of their family members lives.

The provider had invested in an electronic medicines management system. Staff had been trained in its use and completed regular medicines competencies to ensure they were competent to administer medicines. Staff told us the system helped minimise the risk of medicines errors and streamlined the administration of medicines. This meant they had more time to deliver care and spend with people.