EVHM LLP - 25 Alexandra Road

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 which put people at the centre of any development, changes and improvements.

Staff told us how much they enjoyed working at the service and told us they had opportunities to share their views at supervision and staff meetings. They liked the ethos of the service and organisation. A staff member told us that they felt valued, they said, “I know I’m valued, I feel it and I’m part of a team. I feel comfortable speaking with other staff and managers and they support me.” Another staff member told us, “We have a brilliant staff team and manager, and 25 Alexandra Road is homely, and it feels like home."

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 meant there was a stable and effective management team. Staff were committed to people and enabling them to live their best lives. They demonstrated a caring and compassionate approach to people, staff and relatives. They in turn 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. They told us this enabled them extra time to learn new features and ensure that staff were advised of these. They also audited electronic records in terms of how the system was being used. 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. They said they had opportunities to share their views through supervision and staff meetings but also as the service was small, they could meet with the registered manager and the deputy at any point.

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 registered manager and her deputy worked flexibly to support staff well-being and ability to work, adopting flexible working hours and making reasonable adaptions to support staff. A staff member told us they had negotiated their hours to enable a greater work life balance. Another staff member told us they had really appreciated how they had been supported when they had health issues and they said the organisation dealt with this area particularly well with all staff.

There was a formal recruitment process and equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. People were involved as far as possible in this process and given the opportunity to share their views of all potential recruits. 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. Although fire drills were carried out regularly, the records showed how people responded when the alarms sounded but did not record staff performance. This was due to lone working but there were days when there were two staff working on the premises so this could have been achieved. This was raised at the last inspection. Staff were able to tell us what they would do in the event of a fire. Following the site visits the registered manager sent us a new tool that would be used to capture staff performance in future drills.

The last annual survey for people was carried out in 2025 but only one person responded. As staff meet with people regularly to hear their views this had a low impact. 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 will 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.

The quality assurance lead carried out 3 desktop reviews and 1 or 2 provider visits annually to check on the running of the home. From these visits a service improvement plan was drawn up. As part of the reviews the QA lead talked to staff and people to gain their views.

Quarterly meetings were also carried out with all managers, deputies and the QA lead, to look at the electronic systems and see what is working well for the service and what was not and see if everyone was comfortable with the service.

Following the site visit the registered manager sent us revised formats for 6 new tools that would be introduced as part of quality assurance. The audits looked at issues like medicines, analysis of care plans and daily records, health and safety etc.

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 staff team engaged with the local communities and partners. This included GP’s, nurses and others involved in their care and support. A specialist nurse practitioner contacted the home weekly to check if the home needed support in any way. A health professional told us, “It’s a good service, they contact us appropriately by phone and email, its well run and they know people well.”

The registered manager told us she had opportunities to attend a regular network meeting for registered managers. She told us she found the meetings, “Very useful to get information and learn about things and get to meet other managers.”

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.

Staff told us that apart from additional training on mental health they were offered opportunities for further training. For example, each of the senior staff had additional responsibilities which ensured the smooth running of the service. We were told regular meetings were held with other managers within the organisation so that there were opportunities to share ideas and give support to each other.

The registered manager told us they had asked to be a part of STOMP (stopping the overuse of medicines of people with learning disability, autism or both with psychotropic medicines). Whilst waiting on a formal response she had access to webinars in the interim.

One person told us they used the recycle bins for all cans and packaging. Staff told us they encouraged people to recycle and to make it part of their daily lives.