Primrose House

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 the last inspection we rated this key 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.

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 management team had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity, inclusion and ensuring this was reflected in the way staff worked with people and the local communities. They were supporting staff to ensure the service always put people first and delivered care that met people’s needs. Staff had strived to ensure the service put people first. A person said, “It is a lovely and have no concerns. The staff are very good.”

The service had not always 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. There was no registered manager, and 1 had not been in post since 2023. Over the last two years several managers had come into post but none became registered. During the inspection the director of operations submitted an application form to become the registered manager, which needed to be progressed. The regional management team had been in post less than three months and they were in the process of reviewing the service and taking action to make improvements to how it operated. They had identified the issues we found and had developed an improvement plan, which they were ensuring was implemented.

The new management team fostered a positive culture where people now felt they could speak up and their voice would be heard. People, relatives and staff told us they felt confident to raise concerns with the management team and these would be listened to and acted upon. Staff felt their views and suggestions were actively taken on board. A staff member said, “I can raise anything with [deputy manager] and feel these taken seriously.”

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider and management team valued diversity and ensured they followed best practices guidance.

The management team took over the operation of the service late 2024 and they have been working to ensure there were clear responsibilities, roles, systems of accountability and good governance in place. Relative said, “There seems to be one main carer in charge 6 days a week, [deputy manager], but they are struggling with the amount to do,” and, “Initially there was a new manager who left, then another new manager who left so there is no continuity!” There was an audit programme in place which reviewed medicines systems. Actions were recorded however these actions were not reflected in the answers for the audit. For example, one audit action stated ‘as required’ protocols need completing yet the question in the audit was marked as compliant. There had been an issue with the syncing of the electronic medicine administration records and the detail in protocols, which the management team immediately reviewed and addressed. Since the new regional management team came into post less than three months ago, they have been critically reviewing the service and ensuring action was taken to make improvements however these were not yet all embedded into practice. They were in the process of strengthening the audits to ensure they picked up the full range of issues a service might face.

Staff clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They shared information and learning with partners and collaborate for improvement. People reported they found the staff closely tailored their work to individual’s needs and had supported them to experience positive outcomes.

The management team focused on continuous learning, innovation and improvement across the organisation and local system. They were working to encourage creative ways of delivering equality of experience, outcome and quality of life for people. The systems they had put in place to assist staff learn lessons, make improvements and innovate had only recently been introduced and these needed to be embedded.