The Evergreens 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 good. At this assessment the rating has changed to requires improvement: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. Oversight systems were not sufficient to ensure the quality and safety of the service.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 54 (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 vision to provide high quality care to people, and staff shared this vision. However, the provider did not always convey a culture which was based on transparency, equity, equality and human rights and engagement.

The registered manager spoke passionately about providing people with the best care possible. They were accessible to people and we observed them demonstrate kindness, compassion and they supported and reassured people in a caring manner.

The registered manager had a set of values they expected of staff. These included, supporting people with dignity, compassion, with integrity. Staff and the registered manager demonstrated this during our inspection.

A healthcare professional described the registered manager as treating the staff and people, “With respect, courtesy, kindness and compassion.”

Shortly after our site visit we became aware of the challenging relationship between the registered manager and provider. We received several concerns from staff about the negative impact the provider was having regarding the culture in the home. The provider responded to feedback we gave and stated they would be overseeing the home directly on a daily basis, to ensure continuity of care, safety, and operational standards. However, we have not assessed the effectiveness and sustainability of this.

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.

At our last assessment we identified areas for improvement that were shared with the provider. During this assessment we found similar shortfalls remained regarding oversight of the service.

During the site visit staff told us they were supported by the management team in their roles. However shortly after the registered manager resigned, we received several concerns from staff regarding the way the provider led the service. Staff told us the provider was not demonstrating inclusive behaviors in an open and compassionate way.

The registered manager was seen as compassionate and competent by relatives and staff. A healthcare professional told us the registered manager, “Listens to any concerns or issues and takes them forward in an appropriate manner to resolution.”

People did not always feel they could speak up and that their voice would be heard. Shortly after our visit, we received several concerns from staff who did not feel able to speak with the provider about their concerns. The provider had policies in place to enable staff to speak up such as their whistleblowing policy, however staff did not feel able to approach the provider and were fearful of potential repercussions, therefore they raised their concerns with us.

A member of staff described the registered manager and deputy manager as being, “Very approachable if I had any concerns, worries or needed any advice.” Staff had daily handovers and team meetings were held every few months. Staff received regular supervisions, and these were an opportunity to discuss any areas of improvement, training and their learning needs.

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

Staff felt supported to give feedback to the registered manager and were treated equally, free from bullying or harassment. There were fair recruitment processes in place, which helped to protect the rights of staff under the Equality Act. Risk assessments and any reasonable adjustments were utilised, if required for staff. There was a diverse staff team working in the service and open communication supported equality and inclusion. We observed staff working together and communicating effectively with each other during our visits.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems and processes to monitor the quality and safety of the service were not robust and did not identify the shortfalls we found during our assessment in several areas including infection prevention and control, staff training, safe environment and medicines management.

The registered manager told us they completed medication audits, and the provider also completed a monthly audit. However, the provider did not identify the issues we found during our assessment.The provider responded to feedback we gave and stated they would be overseeing the home directly on a daily basis, to ensure continuity of care, safety, and operational standards. However, we haven’t been able to assess the effectiveness and sustainability of these plans.

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.

We found referrals were made appropriately and professional advice was updated in people’s care records for staff to follow. Collaboration with external stakeholders included healthcare professionals, local authority social work and safeguarding teams. Health care professionals gave positive feedback, and we found that meetings and reviews had been held to discuss people’s needs and plan how best to meet them.

The service had an activities co-ordinator in post. We heard from people and their relatives that they had opportunities for meaningful activities. We were told people were supported by staff to access the local community for shopping and recreational purposes which they enjoyed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation, shortfalls identified at previous inspection remained during this inspection.

The registered manager and provider had not always identified necessary improvements , but they were responsive both during and after this assessment and acknowledged where improvements were needed.

The registered manager told us they were developing an improvement plan to address shortfalls, however this had not been implemented. The provider responded to feedback we gave and stated they would be overseeing the home directly on a daily basis, to ensure continuity of care, safety, and operational standards.

The registered manager told us they undertook lessons learned from incidents and accidents. These were monitored and analysed for themes and trends. For example, we saw action taken such as use of a sensor mat to alert staff which has reduced the number of unwitnessed falls. Staff told us the management team shared this learning with them for improvement and development.