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Ebony House Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 4 June 2019

About the service:

Ebony House is a residential care home that was providing personal care to eight people with a learning disability or autistic spectrum disorder at the time of the inspection.

People’s experience of using this service:

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons, lack of choice and control, limited independence and limited inclusion.

The provider did not follow appropriate safeguarding procedures to ensure people were safeguarded from abuse and unlawful deprivation of liberty.

There were several health, safety and infection control issues which put people at risk of potential harm.

The provider did not deploy staff suitably to ensure their needs were met safely.

Risks to people's health, care and mobility needs were appropriately assessed and mitigated.

People were supported by staff who knew how to provide safe care.

Staff recruitment checks were carried out to ensure they were safe to work with people.

The provider lacked robust and effective systems and processes to ensure the quality and safety of service.

People and relatives told us they felt safe with staff. Staff knew how to safeguard people against harm and abuse.

People, relatives and staff told us the management was approachable.

Rating at last inspection:

Good (report published 15 August 2017)

Why we inspected:

The inspection was brought forward due to information of risk or concern.


We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 around safe care and treatment, safeguarding service users from abuse and improper treatment, and good governance. Details of action we have asked the provider to take can be found at the end of this report.

We made a recommendation in our inspection report, which we will follow up at our next inspection.

You can see what action we told the provider to take at the back of the full version of the report.

Follow up:

We will work with the provider following this report being published to understand and monitor how they will make changes to ensure the service improves their rating to at least Good.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 4 June 2019

The service was not always safe.

Details are in our Safe findings below.



Updated 15 August 2017

The service was effective. Staff received up to date training and appropriate support through supervision and appraisal meetings.

Staff had a clear understanding of the application of the Mental Capacity Act 2005 to practice.

People's care and support needs were assessed and reflected in support records. People were supported to maintain good health and to access health care services and professionals when they needed them. People had access to enough food and drink.



Updated 15 August 2017

The service was caring. People told us the service was caring and staff treated them with respect and dignity. Care and support was centred on people's individual needs and wishes. Staff knew about people's interests and preferences.

People using the service were involved in planning and making decisions about the care and support provided at the service.

The service enabled people to maintain links with their culture and religious practices.



Updated 15 August 2017

The service was responsive. People's care and support needs were assessed and individual choices and preferences were discussed with people who used the service and their relatives. People�s support plans were regularly reviewed.

People were able to take part in a programme of activities in accordance with their needs and preferences.

People were encouraged and supported to provide feedback about the service. There was a complaints process and people using the service knew how to complain.


Requires improvement

Updated 4 June 2019

The service was not always well-led.

Details are in our Well-Led findings below.