Evergreen Manor Care Home

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 inspection we rated this key question good. At this inspection 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 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.

The management team supported an open culture and had created a strong team ethos. Staff spoke positively about working at the home and felt well supported in their roles. One staff member told us, “We all work together as a team to do the best we can for the residents. The residents are our number 1 priority.” Another staff member said, “I believe everyone who works here does so because they care for the residents and want them to be happy and safe.”

Processes to involve people and staff in developing the culture included seeking people's feedback through meetings and questionnaires on the quality of care and service provided. Where suggestions were made, action was taken.

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.

People knew who the management team were, and how to contact them. One person told us, “The manager is approachable, and I would feel able to raise any concerns if needed.” Relatives told us they had a good relationship with the manager and staff team and were happy with the service provided to their loved ones.

Staff understood their roles and responsibilities and told us they felt valued and supported by the management team. One staff member said, “The manager makes you feel valued. They thank you for what you do.” Another staff member told us, “The manager supported me to attend an emergency appointment whilst dealing with a personal issue. The manager showed real empathy."

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

Staff felt confident to raise any issues or concerns with the management team if needed. One staff member told us, “If I had any worries, I would report them to the manager who would act on them straight away.” The provider also held regular team meetings, where staff had the opportunity to raise concerns and offer suggestions. One staff member told us, “We do have team meetings, but the manager will say, if you don’t want to speak up here you can always come and talk to me separately.”

The registered manager understood the need to be open and honest when things went wrong in line with their responsibilities under the duty of candour.

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.

Staff told us they felt included in decisions about the service and enjoyed working for the provider. One staff member told us, “I know if we have a suggestion and it would improve things, the manager acts. We are encouraged to share our ideas. Two heads are better than 1.”

All staff had received equality and diversity training. The provider’s policies promoted equality and diversity, and a diverse staff team has been recruited to support people living at the service.

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.

Systems and processes were in place to monitor the quality and safety of the service. However, we found some control measures to mitigate risks were not always followed by staff. For example, a prescribed thickening agent was not locked away and we observed 1 member of staff wearing jewellery. Despite these shortfalls, which were addressed during our visit, the management team demonstrated a commitment to ensure the improvements made were sustained to ensure people consistently received good care and achieved good outcomes.

The registered manager told us, “Knowing and understanding each person’s needs, ensuring they are well cared for, is really important to me.” The registered manager demonstrated an understanding of the regulations and their responsibilities. For example, they had informed us about important events within 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.

Staff worked in partnership with health and social care professionals to ensure people had the best outcomes for their health and wellbeing. People confirmed this. One person said, “Staff know what I can and can’t eat and my medication is in order, and I have them on time."

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 felt supported by the provider and spoke about opportunities available for their personal development. One staff member told us, “I really enjoyed my induction, I spent time learning about the home, what I had to do, and I met all the residents. Everyone was friendly and supportive.”

Staff recorded incidents and accidents. These were reviewed by the registered manager and action taken to prevent reoccurrence. Any lessons learnt were discussed in team meetings.