Evington Home - Pilgrims' Friend Society

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.

The provider’s vision, known as ‘fulfilled living for older people’, was based on their core values of offering a caring, person-centred holistic approach which considered people’s individual and spiritual needs.

Managers and staff and demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. The culture focused on facilitating mutual trust between everyone involved with the service as well as learning and improvement.

People, staff and relatives said the service provided a happy, homely place for people to live and work. They commented on the ‘calm environment’, ‘really lovely atmosphere’, and ‘good structure and routine’.

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 always did so with integrity, openness and honesty.

At the time of our inspection visits the registered manager was new in post and not all relatives had met them. Those that had, told us the registered manager was ‘very kind’ and ‘very approachable’. A relative said they had met the registered manager several times to talk about their family member’s health and had ‘peace of mind’ because the service was ‘well-managed and very good’. Staff made many positive comments about the registered manager and said the service was well-led.

The service’s operation manager and chief executive officer (CEO) supported the registered manager and staff. They visited the service regularly and met with the people using it to get their views on the quality of care provided. They were knowledgeable about the service’s issues and priorities and made resources available when they were needed.

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

People, relatives, visitors, and professionals were invited to complete annual quality assurance surveys so they could share their views on the service. Relatives’ meetings were held where attendees could share concerns, ask questions, and collaborate with staff on care plans.

Residents’ meetings provided a platform for people to voice their opinions, share ideas, and influence aspects of their care home life. Records showed people’s suggestions, for example ‘to reduce food waste’ and ‘not start Christmas too early’, were turned into actions demonstrating that people were listened to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for the people who worked for them.

The service employed a multicultural workforce who understood the service was based upon Christian values as this was explained to them during the recruitment process. Staff were trained in equality and diversity during their induction to ensure they understood the provider’s commitment to inclusion.

Policies and procedures on anti-bullying and harassment were available to staff on the provider’s intranet. The registered manager had an open-door policy and encouraged staff to come to them if they had any concerns about inclusion. Staff said they would be confident to speak up if they needed to.

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.

Managers followed the provider’s audit system to oversee and monitor the service. The registered manager focussed on care and staffing, and the business manager on finance and health and safety. Audits showed shortfalls were mostly identified and action taken to address them. The service’s operations manager carried out monthly audits which, over the course of a year, covered all aspects of the service. This scrutiny helped to ensure that the service was running safely and effectively.

The provider’s CEO visited annually to discuss the company’s vison and values and ask what was needed to improve the service. The registered manager said at the last meeting in September 2025 they asked for a dedicated medicines room to make medicines management and storage easier. This was agreed with the work due to go ahead. This showed a commitment to listening to staff and to continually improving the service.

The registered manager submitted notification to CQC in line with their legal responsibilities. Notifications are about certain changes, events and incidents that affect the service or the people who use it. By informing CQC the provider helped to ensure we were aware of what was happening at the service.

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 service employed an Activity Community Engagement (ACE) facilitator who connected people with local churches, volunteers, and other community groups including schools and colleges. Clergy and volunteers from local churches were regular visitors to the service, building relationships with people and contributing to bible and prayer meetings.

People went out on trips to garden centres and to watch plays performed by school and college students. The ACE facilitator organised a monthly community café for members of the public where they could learn about the service and the role of volunteers there. A local church group helped to care for the service’s gardens.

By collaborating and working in partnership with local organisations and members of the public the provider helped to ensure that people using the service were not isolated. Instead, they benefited socially and spiritually from contact with the wide variety of volunteers and supporters who visited them at the service.

The provider focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice.

The Way We Care, the provider’s approach to caring for older people, was based on practice and research. This recognised that at the heart of dignified, respectful care was the ability to see the whole person and respond to them where they were, giving them opportunities to contribute to life within a community.

The service had processes in place to learn lessons and bring about improvements. Systems were in place to identify learning from feedback from people, relatives, and staff, audits, accidents/incidents, and complaints and safeguarding’s. Managers welcomed feedback, both positive and negative, and took immediate action to address the issues we identified during our inspection.