Evergreen Lodge

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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation 17 and 18 in relation to governance and staffing at the service.

This service scored 36 (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 did not always demonstrate a clear shared direction or culture across the service. Expectations around openness, accountability and good practice were not always consistently understood or followed by staff.
Information provided about staff training was not always consistent or reliable, the training matrix provided did not evidence what staff were telling us, this reduced the assurance and oversight the provider had of its staff’s competence. We observed care records being completed by one staff member on behalf of another. This raised concerns about accountability and the reliability of records.
When staff brought up concerns within staff meetings these were not always listened to for example, staff requested the fridge to be reinstated on the units however this was not agreed as the registered manager did not feel staff were looking after it. However, the removal of the fridge had caused an issue of appropriate cool storage for foods that had not been remedied.
Staffing levels were reduced on units without prior discussion with the staff. Staff we spoke with told us they were unsure why these changes had been made and said the registered manager told them there were sufficient staff despite their concerns.
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.
The service was operating under the incorrect service user banding. Service user banding describes the type of support a service is registered to provide, based on people’s needs, for example, nursing, residential or people over 65. By not ensuring the service had the right service user banding registered with CQC demonstrated a lack of awareness of their regulatory responsibility.
The service did not ensure all staff at leadership level had the appropriate training, this included the lack of information governance and GDPR training. CCTV was being utilised without clear signs to inform people, this alongside lack of training, raised concerns regarding the understanding and safe management of people’s personal information.
All staff spoken with were happy with the support they received from the management team, one staff member told us, “[manager] is approachable and visible, they [manager] interact with all staff and residents.”
 

Staff told us they were confident in speaking up if they needed to and were able to demonstrate the steps they would take if they felt they weren’t being listened too. One staff member said, “I would always go to the nurse on duty, if I am not happy, I would then go to the manager.”
There was a whistle blowing policy in place and staff were aware of how to utilise this if required.
However, a professional we spoke with told us, “I do get the impression from the nurses that they care and are knowledgeable, but it feels almost like they can’t make an autonomous decision without checking with [manager].’
 

The provider did not always value diversity within their workforce. They did not consistently work towards an inclusive and fair culture by promoting equality and equity for all staff.
The management team had not ensured that all staff received equality and diversity training. While training records showed 100% compliance, this did not include auxiliary staff, who had not completed the training. This highlighted a lack of recognition of the importance of ensuring all staff, regardless of role, receive equality and diversity training to support an inclusive workplace culture.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The auditing system in place was not effective; actions were not always recorded when a concern had been identified.
Audits were being signed off as completed; however, an action had been recorded therefore it was not clear whether this action had been completed.
Monitoring of accidents and incidents was not consistent and did not provide effective oversight. Different recording systems were used and behaviours that challenge were recorded within behavioural charts but were not consistently included in the accident and incident records. This meant leaders did not always have correct information regarding incident to allow for analysis and review trends and themes to prevent further incidents.
Health and safety concerns were not always acted upon. For example, water temperature checks identified a scalding risk however, no action had been taken to reduce this risk. Additionally, the service did not adhere to its own policies, for example their recruitment policy recorded the incorrect service user banding, and the training policy stated all staff had received ‘Oliver McGowan training.’ Only 2 members of staff had received learning disability training.
The restraint register was inaccurate. As a result, management could not be assured all restraint incidents had been reviewed, monitored or used to reduce further incidents and mitigate risk.
 

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.
When people were assessed as lacking capacity there was not always evident an advocate had been involved in decision making where this was required, which indicated gaps in partnership working with the advocacy service.
Professionals we spoke with were positive about communication between the service and themselves.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.
Where concerns had been identified and lessons learnt it is not clear how this learning was shared. The registered manager told us information was shared during daily meetings however, these are only with the heads of departments and at times heads of department were not in attendance therefore it is not evident how this learning is shared to ensure it is embedded into practice.
When there had been incidents where people required restraining lessons learned were not always recorded or acted upon this was evidenced in repeated episodes of restraint.