Primrose House 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. This is the first assessment for this service. This key question has been rated 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 75 (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 registered manager and staff demonstrated a clear understanding of the providers core values and spoke enthusiastically about the service's positive culture. The registered manager shared insights into the service's developmental journey, highlighting the improvements being implemented and demonstrating a commitment to continuously enhancing the quality of care and experiences for people.

Systems and processes were in place to ensure staff were well supported and equipped with the skills and knowledge to promote a positive culture within the home.

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.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. People, relatives, and staff consistently spoke highly of the management team. Comments included, "The management team are great and very approachable. The registered manager communicates really well with everyone and will support in any way they can." And "The management are lovely and personable. They are quick to action anything we need."

The registered manager was visible, responsive, and actively involved in care delivery, contributing to a strong sense of trust and confidence in the leadership The provider's systems and processes ensured all staff understood their roles and responsibilities, and knew when and how to escalate concerns.

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

People, relatives, and staff felt confident raising concerns, knowing appropriate action would be taken. There was a clear complaints policy available, with guidance provided in various formats to ensure accessibility. When complaints were raised, they were logged along with details of any resulting actions. Staff were aware of the whistleblowing procedures and felt supported by an open-door policy that encouraged transparency and speaking up.

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 valued diversity and fostered a positive culture. Regular team meetings supported staff to share ideas and concerns to improve the service. Staff achievements were acknowledged through awards and staff told us that the management team regularly expressed appreciation for their contributions in the service. One staff member told us, "Management praise us when things go well and are always available if we have any problems."

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.

Systems and processes were in place to ensure effective governance and oversight to ensure the delivery of safe, effective, person-centred care. A range of audits were regularly conducted, covering areas such as medicines management, health and safety, and incident and accidents. These audits were effective in identifying areas for improvement and driving positive changes.

The management team carried out daily walkarounds and spot checks to maintain standards and address any issues promptly. A detailed provider-level audit added further oversight, supporting continuous improvement and accountability.

Both the provider and registered manager evidenced strong governance structures, with clear roles, responsibilities, and systems of accountability. They used accurate information to support decision making which was shared with staff and partners when needed.

Statutory notifications to the CQC were completed as required, and the registered manager worked with the local authority to ensure safeguarding concerns and people’s safety was prioritised. Workforce planning was well-structured, with recruitment and staff development appropriately managed, to meet the evolving needs of the service.

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.

The service worked well with a variety of healthcare professionals. The service had formed a positive partnership with a neighbouring school. Together, they organised shared activities such as storytelling, arts and crafts, and seasonal celebrations. These events were open to the wider community, fostering local engagement and strengthening community connections.

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.

Existing systems and processes were actively used to review and implement ongoing changes and drive improvements throughout the service The provider was in the process of introducing a streamlined, fully electronic auditing system, which the registered manager was fully embracing whilst continuing to use current systems to ensure safe and effective practices.