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 requires improvement. At this assessment the rating has changed to 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 71 (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.

At the last inspection we identified shortfalls in relation to the culture of the service. At this inspection improvement had been made. Relatives were positive about the culture created by the management team, who they felt were open and approachable. The manager said they had tried to create an open, no blame culture where there was opportunity to learn from mistakes and make improvements. The management team told us the provider supported them to implement this vision. Staff told us the manager had worked hard to change the culture in the service, and they felt supported by the provider and management team. Comments included, “The culture in the home had become more honest. There is no blame when things go wrong but [a focus on] learning from things.”

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.

At the last inspection we identified shortfalls in the capability of the management team. At this inspection improvement had been made. The service had a manager who had applied to be registered with the Care Quality Commission. People and relatives told us they knew who the manager was and were confident they would resolve any problems raised with them. People felt the service was well managed.

Staff told us the manager was open and approachable, and said they had made a lot of improvements to the service since they had been in post. Comments from staff about the management team included, “good manager”, “approachable and listens to staff” and “calm and approachable.”

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

Staff told us there were effective systems for them to raise any concerns and they felt confident action would be taken if they used them. Information about how to raise concerns was displayed in staff rest areas. Records demonstrated staff were encouraged to raise any concerns during team meetings and individual meetings with their supervisor, which were followed up.

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 manager told us they had supported staff to make reasonable adjustments to their working patterns where needed, to support them to remain at work. Examples included changes to accommodate caring responsibilities and support for staff to observe their religious and cultural needs. Staff were aware of the provider’s policies and told us they felt very well supported by the management team.

At the last inspection we identified shortfalls in the governance systems in the service. Improvements had been made and the provider was no longer in breach of regulations, although further work was needed to ensure some checks were completed consistently.

The provider now had a governance system, which included a schedule of audits and feedback from people about how the service was operating. The manager used the outcome of these audits to develop action plans to address any shortfalls that were identified. The action plans included staff responsible for taking the action and a timescale for completion. The plans were regularly reviewed with the provider to ensure actions had been completed.

However, some checks of the building had been delegated to a single staff member and had not been completed when this staff member was absent. Systems were not in place to ensure effective oversight of these tasks during staff absence. The manager took immediate action during the inspection to ensure the missing checks were completed. Following the inspection the manager sent us information about new systems they had developed to ensure checks did not rely on a single staff member.

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 manager told us they worked with a range of other professionals to help make sure people received continuity in their care. Relatives gave examples of the service working in partnership with other agencies, including the GP and specialist nurses, to help meet people’s needs. Health and social care professionals gave positive feedback about their experience of working with the service to meet people’s needs. Comments included, “The staff at The Evergreens Lodge have always worked very positively with me and appear to have a very collaborative approach, always looking for ways they can meet my client’s need better.”

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.

Systems for monitoring standards of care were used to identify areas of improvement and lessons learned. This included regular audits and quality assurance checks. The manager was a member of management forums to share learning from incidents in other services. The manager told us they used reflective supervisions to learn from incident and help staff develop their knowledge and skills. Staff confirmed they took part in these sessions and said the manager was focused and learning and improving the service.