Ebenezer Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment and premises and equipment.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty.

While leaders described expectations for concerns to be raised, we did not always see examples that safety events were recorded, reviewed and or used to drive learning and improvement. As a result, learning from safety events was not always embedded or used to support continual improvement across the service. For example, there were no incident form completed for a person where minor injuries had occurred. This meant we could not be assured that safety events were used systematically to reduce the risk of similar incidents recurring across the service.

Relevant policies were in place, but they were not being followed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The deputy manager told us people who used the service had been using the service for a very long time and no one had started using the service recently. The records we reviewed also confirmed this.

People’s needs were assessed before they started using the service to ensure the service was able to meet them. This helped to achieve a smooth transition from one setting to another. People and their relatives were involved in the assessment process, so their views and wishes were taken into account. Relatives we spoke with confirmed this with us.

There was a procedure to follow when a person wished to start to use the service, including the scope of the assessment.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

During our inspection, we found people were at risk of potential harm or abuse. For example, the provider did not complete relevant risk assessments for people accessing community independently. The provider also had not made referrals to healthcare professionals such as Speech and Language Therapist (SALT) when people needed them. Moreover, the provider did not keep records of events where people experienced minor injuries. However, we found no evidence people were harmed.

People said they felt safe with the staff. A person told us, “Yeah, I feel safe here,” when we asked other people if they felt safe with staff. A relative told us, “I think my[relative] is safe at the care home.”

The provider had appropriate policies and procedures in place to guide staff on how to respond to any allegations of abuse. Records confirmed that staff had received safeguarding training, which supported their knowledge and understanding of how to keep people safe.

Staff demonstrated a clear understanding of their roles and responsibilities in relation to safeguarding and reporting concerns. They were able to explain which external agencies they would contact without delay if they witnessed, were informed of, or suspected that a person using the service was being harmed or placed at risk. A member of staff told us, “I will report abuse to the manager and if they will not listen or take any action, I will report the abuse to CQC.”

The deputy manager was aware of their responsibilities in ensuring people were protected from abuse.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider did not ensure all risks to people’s safety and wellbeing were identified or provided enough detail as to how these should be mitigated. For example, the provider did not complete risk assessments for people living with diabetes.

We also found staff were not following people’s risk assessments. For example, a care plan of a person we reviewed stated, “Staff to keep [person] in sight at all times while shopping.” However, records indicated this person had been going out independently. This meant risk assessments were not being reviewed or followed. However, we found no evidence that people have been harmed by these risks. We brought these issues to the deputy manager attention, and they gave us assurances they would complete and update the relevant risk assessments.

There was evidence people were involved in writing their care plans and risk assessments. For example, care plans were signed by people and their advocates.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The management team carried out checks to identify any potential hazards in the service and put measures in place to mitigate those risks. However, we found the system was not robust enough to demonstrate safety was effectively managed. For example. electrical installations condition report dated March 2025 highlighted some issues the provider had not acted upon.

We also found that legionella testing was not carried out. We discussed this with the provider, and they made efforts to contact companies to carry out the testing work.

We observed checks had been carried out on the gas appliances and fire extinguisher.

People had a personal emergency evacuation plan (PEEP) in place. This is guidance for staff on what to do in the event of an emergency, and how to safely evacuate people.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People and their relatives we spoke with were happy with staff. A person told us, “Yeah staff look after me here.” A relative also told us, “I am happy with staff approach. I would panic if I would be there. I get the impression they are trained and know what they are doing.” Another relative said, “I have no cause of concern where staff did not look after my [relative].”

We found people were supported by the same group of staff members who were familiar with their care needs. This helped with consistency and continuity of care as staff were aware of the needs of people they were caring for.

The provider had a training programme in place to ensure staff had the skills and knowledge required to meet people’s needs. However, whilst all mandatory trainings had been completed staff had not received trainings in relation to some specific health requirements of the people living in the service. For example, staff were supporting people with diabetes and schizophrenia, but they had not received any training in this area.

The provider had effective recruitment and selection processes in place which ensured people were supported by suitable qualified staff. We reviewed staff recruitment files and found that all required pre-employment checks had been completed which were in line with current legislative requirements. The provider told us that all staff members were encouraged and supported to complete additional, relevant qualifications with the health and social care industry which enhanced their skills and knowledge.

New staff received an induction when they started working at the service. This included training, familiarisation with policies and procedures, and time to get to know people who used the service. New staff were supported to shadow experienced staff before working independently.

Staff had regular supervisions with their line manager, where they could discuss any concerns or issues. These meetings covered topics such as training needs, and the needs of people using the service. Staff told us they felt well supported by the management team.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The provider did not have an effective approach to assessing and managing the risk of infection as we identified some concerns during our visits.

On the first day of our visit, we found unlabelled and uncovered food in the fridge, and this posed a significant breach of food safety and hygiene regulations, presenting risks of food poisoning and contamination to people who used the service.

During our first visit we saw cleaning material which were not safely stored. We raised this with the provider who responded accordingly safely locking them away which we noted on our second visit.

The care home had an up-to-date infection prevention control (IPC) policy. However, roles and responsibilities in the area of the policy needed to be clearer.

All the staff completed training in infection prevention and control and demonstrated a good understating of the measures to manage and prevent the spread of infection. Staff were provided with personal protective equipment [PPE], and they confirmed they had access to enough PPE.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Systems were not robust enough to demonstrate medicines were managed safely and effectively. This placed people at risk of harm.

During our visit, we found extra medicines in people’s medicine boxes. People’s hospital passports which were recently updated had information which was no longer relevant. This meant healthcare professionals would not have accurate information if they needed it.

The provider did not assess staff for medicine competencies to administer people’s medicines. This meant staff ability to administer medicines safely was not checked.

Medicines audits were carried out by the management team to ensure people had received their medicines as prescribed. However, this did not work effectively. For example, they failed to identified issues with medicines.