Primrose Neurological Centre

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 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.

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 provider and registered manager promoted teamworking. Comments we received included, “We all work well together.” And, “We all have the same aim here and it’s to help people live their best lives. "

We saw the registered manager was known to people and spent time with people if this was what people wanted. One person shared, “I have tried teaching the manager about technology and fashion. She knows about designer tracksuits and caps now.”

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.

The provider employed a registered manager who worked with other stakeholders, people and relatives to shape the service and deliver care.

Staff spoke positively about the management team. Staff said they felt supported, and they were able to discuss any concerns they had with them. One staff member said, “If I need any guidance [registered manager] is always available.” Another staff member shared, “[Registered manager] takes our concerns and acts on them. A relative commented, that they were confident the registered manager would be available if needed.

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

The management team were available during the day and in the evenings, nights and weekends. There was an on-call system where staff could contact a member of the management team if advice was needed. Staff told us they were confident to speak up and believed appropriate action would be taken. Information on how to speak up was on display and accessible.

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 supported 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 adjustments had been made to their working pattern in response to changes in their life.

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.

Audits, feedback and surveys identified shortfalls and improvements were made. For example, transport for the service was being sought after feedback from a survey had identified this as a need. Audits on areas such as medicines, infection prevention and control, equipment and accidents and incidents were completed and learning from these were shared with staff. Staff told us lessons learned were shared and documentation we viewed confirmed this. This helped drive improvement.

The provider understood their duty to collaborate and work in partnership, so services workedseamlessly for people. They shared information and learning with partners and collaborated for

improvement.

The registered manager worked with external stakeholders to improve the service. They shared information promptly and supported shared decision making which placed people at the centre of their care. A visiting health professional shared that staff took time to listen and act on professional feedback.

Care records demonstrated the involvement of health professionals and how the advice given would be acted upon. Records also showed if further changes were required, relevant health professionals were informed and guidance was sought.

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.

Regular meetings were held to share information and lessons learned. The provider shared information from learning at other services to promote continuous learning and improvement. When appropriate, this was discussed and changes made to improve the service provided.

Audit processes were followed and results were analysed to identify what worked well and where there were shortfalls. Actions were completed and support and oversight from a regional manager helped ensure consistent improvements were made. Records of meetings showed that successes were celebrated with staff.

A visiting health professional shared that they considered the service explored innovative ways to support people’s engagement in meaningful activities.