Primrose Lodge

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• 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

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 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

Description: We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service 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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. All of the staff we spoke with were passionate about being involved in peoples’ recovery and clients told us they recognised and valued this.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. We saw evidence of managers involving staff in discussions about changes to the service and allowing them to offer feedback and suggestions. Major changes within the service were subject to a formal consultation process.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service 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 and experience to perform their roles. The registered manager had worked at the service since 2015 and been in their current post since 2021. They also had experience of managing other services delivered by the provider. They demonstrated a passion for the service they delivered and were committed to ensuring a positive experience for clients and staff.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible in the service and approachable for clients and staff. Staff told us they had open and honest relationships with the managers of the service. Staff at all levels also told us they would feel confident contacting senior leaders if they needed to. Senior leaders frequently visited the service. The facilities manager was on site during our inspection and the head of therapy and quality assurance manager frequently visited the service.

Leadership development opportunities were available, including opportunities for staff.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Clients and relatives had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Staff held weekly community meetings where clients were encouraged to provide feedback about any aspect of their care. There was also a suggestions box in the reception area, although there were no cards/paper or pens nearby to encourage people to utilise this.

Managers and staff had access to the feedback from clients, carers and staff and used it to make improvements.

The provider had a whistleblowing policy and the organisation had a Freedom To Speak Up Guardian for staff to raise concerns.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff are able to apply to request updates to their working patterns, e.g. we saw that a staff member had recently requested to move to work night shifts which had been accommodated.

All staff received training in the Equality Act 2010, and diversity and equality.

Staff we spoke with did not report any concerns regarding equity and diversity.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always have processes in place to identify areas of service provision that needed improvement.

There was a clear framework of what was discussed in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. Incident themes, outcome of investigations, safe practices, and client feedback were standard agenda items for discussion in staff meetings and clinical governance meetings.

Staff participated in clinical audit and had a comprehensive auditing programme in place which included topics which were audited on a daily, weekly, monthly or quarterly basis. These then fed into a monthly report for assessing overall quality. However, some of the issues we identified during our inspection such as clients’ needs not being fully addressed or considered during the assessment process had not been picked up within the provider’s auditing processes.

The service had recently started using an online audit tool to record actions set and completed in areas such as health and safety, electronic care records, and medication.

Staff had implemented learning from incidents and complaints at service level.

Staff maintained and had access to the service’s risk register. Staff could escalate concerns when required. The registered manager regularly updated the risk register.

The service also had a site improvement log which the registered manager regularly updated. Feedback from our inspection was promptly added with suggested ways to mitigate any concerns raised.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well.

Information governance systems included confidentiality of client records.

The registered manager had access to information to support them with their management role. This included information on the performance of the service, staffing and client care.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

Managers described positive relationships with key external stakeholders. The service liaised with the local authorities safeguarding team when needed. However, colleagues from the local acute hospital told us there was no working relationship with the service. The registered manager told us they had invited colleagues from the hospital to the service to meet with them and learn more about it, but this request had been declined.

Staff could meet with members of the provider’s senior leadership team to give feedback. Staff told us they wouldn’t hesitate to pass feedback onto the organisation’s senior leaders.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation.

Managers told us that learning and innovation were the ethos of the team. They told us that there was a clear focus on this now the new senior leadership team were in post within the organisation. One example of this was the new electronic auditing system which was now in place.

Staff were given the time and support for improvements and innovation and this led to changes. The administration lead gave examples of new processes they had implemented in their new role which had been shared with other services run by the provider.