EVHM LLP - 24 Tower Road West

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.

This is the first assessment for this newly registered service. This key question has been rated 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 deputy manager shared a clear vision of the future and direction of the service. People were involved in any development, changes and improvements. Staff spoke positively about the service and confirmed they had opportunities to share their views on the running of the service at supervision and staff meetings. They liked the ethos of the service and organisation. A staff member told us, “I feel valued, people are pleased to see me. At Christmas, head office gives us handwritten Christmas cards, and they always greet us with friendship and kindness.”

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 registered manager had been in post for several years and worked alongside a deputy manager and a number of other staff who had also been employed on a long-term basis. This gave consistency and stability to people and staff. Staff demonstrated kindness, enthusiasm and a commitment to helping people live their lives to the full. The staff team were supported by a quality lead and directors who were equally engaged with the service and staff told us they were very approachable.

Senior care staff had taken on additional roles. For example, one senior was a champion on the home’s electronic system. A ‘champion’ is a member of staff who has a special interest in a certain area of care and will cascade the learning to the team. Other senior staff had ‘champion’ roles in relation to health and safety and infection prevention and control.

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

Staff told us they were able to speak to the management team about any concerns and had access to whistleblowing information and guidance if required. Staff said they could share their views through supervision and staff meetings but also as the home was small, they could meet with the manager and the deputy at any point.

People had opportunities to share their views through keyworker meetings and house meetings, and they told us they could speak with the manager or deputy when they needed to. We could see the relaxed rapport people had with staff, and that people were happy to engage with staff on a variety of topics.

People’s relatives told us they felt comfortable raising any concerns or worries and that they would be confident concerns would be taken seriously. A relative told us, “It’s like one big family, but if I had any concerns the staff are all approachable.”

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.

People were cared for by a diverse staff team. Staff told us the manager and deputy recognised their individual needs and respected them. They told us they enjoyed working at the service and felt valued. A staff member said, “They do appreciate the work we do, and we can put forward ideas and they do listen.”

The provider had an equality, diversity and inclusion policy in place which set out how they were committed to ensuring those employed were free from harassment, bullying, victimisation and unlawful discrimination. Staff completed training on equality and diversity.

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.

The registered manager and deputy manager had good oversight of the service and any risks, along with the quality of people’s care and support. The last annual survey for people was carried out in 2025. As a result, there was a, ‘You said and we did,’ response sent to people showing the actions taken in relation to the issues they raised.

The staff survey was carried out in August 2025. 9 of the 17 staff that worked across three houses completed the survey. An action plan was drawn up to address any actions needed but overall, the response was very positive. The provider advised that moving forward, as part of their quality assurance review for the whole company, the structure of analysis and responding to staff would be reviewed.

There were clear policies and procedures in place and staff followed these. The provider was aware of their statutory responsibilities to notify CQC about certain changes, events and incidents that affected their service or the people who use it. These notifications were submitted appropriately.

There were systems to carry out regular audits of the service to make sure it was running effectively. The quality assurance lead carried out 1 or 2 provider visits annually and any shortfalls were identified in an improvement plan. Follow up desktop reviews were then carried out to review progress with the improvement plan. The registered manager spoke about the continuous cycle of assessment and review and how they were making improvements all the time because of this regular focus. The provider also had a business continuity plan, to help ensure the service could continue running during and after any disruptions.

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.

There was regular engagement with people and their families, and the service worked hard to create links with local communities. The registered manager told us she continued to attend a regular network meeting for registered managers. One person and a staff member who had completed a half marathon used this as an opportunity to raise money for a local charity. The charity and the person’s day centre along with the staff team all recognised the achievement and celebrated the person’s contribution.

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 and research.

The provider focused on continuous learning, innovation and improvement across the organisation. Staff had opportunities to develop their skills and knowledge.

Staff told us they felt the training provided met their individual needs and those of the people they supported. The registered manager confirmed that they were continuing to try to source enhanced training on mental health for the staff team. Some staff had additional responsibilities which ensured the smooth running of the home. Contingency and improvement plans were in place and there was an ethos of learning at the home, when things went wrong or when there were successes, these were all documented and discussed with staff.