Evergreen

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 requires improvement. At this assessment the rating has changed to 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 were committed to delivering good-quality, person-centred care. The registered manager was open, honest and transparent. They were aware of their strengths and areas they needed to develop. By working together with the staff, the registered manager ensured an inclusive culture, with a strong focus on learning and continuous improvement.

There was a friendly and open culture throughout the home, staff told us they felt included and part of the team.

Staff understood the homes values and were committed to delivering good-quality, person-centred care. We observed a positive learning culture within the service, and staff said they felt able to speak up because they knew concerns would be taken seriously. Daily meetings and handovers were used to share learning from incidents and safeguarding matters to help improve practice.

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 and experience to lead effectively. They did so with integrity, openness and honesty.

The registered manager was committed to supporting people and staff and was described as kind and approachable. They were receptive to feedback during inspection and used this to implement positive changes. They were keen to improve and provide the best care possible for people, whilst ensuring staff were included in changes and felt empowered.

The registered manager ensured staff were supported and had access to the information they needed to safeguard people and provide the best care possible. They showed compassion and it was evident they really cared about the people living in the service. Feedback from health professionals included how the registered manager expressed genuine concern when people moved out to ensure that their care needs continue to be met when they returned home, including concerns about social isolation.

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

The registered manager encouraged openness and listened to people’s views. People told us they would feel comfortable raising any queries or complaints if they needed to. Staff ideas were listened to, valued and used to implement change.

A whistleblowing policy was in place, this included key principles of freedom to speak up. Staff told us they were aware of the whistleblowing policy and felt they would be supported if they raised any concerns.

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.

There was a robust recruitment process in place to ensure fair recruitment and selection processes. Staff felt they were treated equally. The registered manager valued diversity and promoted an inclusive and fair workplace. An equality and diversity policy was in place, and the workforce reflected the diversity of the local community.

The provider had clear responsibilities, roles, systems of accountability and 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.

Quality audits, risk assessments, and improvement plans were in place and regularly reviewed.

The registered manager demonstrated accountability and acted promptly on identified risks, such as improving areas of documentation and environmental issues. While overall care plans were person centred, some improvements were needed to ensure information was clear. Handwritten changes to care plans meant it was not always easy to see exactly what information was current. However, care staff knew people extremely well, so risk was mitigated. The registered manager was looking at implementing electronic care plans in the future and acknowledged improvements were needed. This had already been included in their ‘Future plan and review for 2026’.

A clear audit trail of health professional input and visits was in place for each person. This gave a robust oversight of all telephone calls and visits along with a record of people’s weights and any updates and changes to care needs identified.

The registered manager had oversight of environmental risks and all appropriate checks and servicing had been completed.

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 registered manager worked with external professionals and agencies to support people’s care and promote continuity. They had established good working relationships with other health professionals involved in people’s care and nursing needs. We saw this in practice when a person who had been newly admitted required treatment to assess their current medication regime for a dose-specific medication. The registered manager liaised with a number of professionals until this was arranged. This collaboration supported positive outcomes for people using the service.

The registered manager recognised the importance of learning and improvement and had taken steps to reflect on practice. Some improvements were evident, and all staff showed willingness to work together to adapt and develop the service.

The registered manager demonstrated commitment to learning and improvement. Lessons from incidents and safeguarding concerns were reviewed and shared with staff. Staff were supported to complete further training and gain extra qualifications specific to their job role. Staff confirmed that extra training had been provided to ensure they were able to meet a person’s changing nutritional needs. This increased staff knowledge and confidence, supporting them to carry out their role to the best of their ability. The registered manager and clinical staff maintained their revalidation through continuous learning and reflection.

The registered manager welcomed feedback to improve people’s outcomes and the quality of service provided.