Ebenezer Residential 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

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.

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

This service scored 57 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people.

Front‑line staff demonstrated values of kindness, respect and person‑centred care in their day‑to‑day practice, and people were generally treated with dignity and supported as individuals. However, the provider did not demonstrate a clearly articulated or consistently understood shared direction across the service. Relatives were not involved in care reviews and best interest meetings. As a result, while positive values were evident in care delivery, the absence of a consistently shared and embedded culture at leadership level reduced assurance that people’s rights, lived experience and voices were always central to decision‑making across the service.

The nominated individual told us they operated an open-door policy, allowing people, their relatives, and staff to speak with them at any time.

Staff reported that the registered manager was approachable and easy to talk to if they needed to raise any concerns.

Not all leaders understood the context in which the provider delivered care, treatment and support.

We found policies were incomplete and also were not updated. For example, roles and responsibilities within some policies lacked ownership and accountability.

We also found some policies were not being followed. Requirements for reviewing people’s care was not carried out in line with the provider’s own policies and there was a lack of clarity from senior leaders.

There were systems in place for communication between staff and the management of the service through staff meetings, and staff handovers. Despite these systems, not all information was successfully implemented and recorded in people’s care plans. For example, care plans which were reviewed and updated recently did not have the accurate information about people’s current needs.

The provider had not completed the annual CQC Provider Information Return (PIR) form which CQC sent them in September 2025. They were given 28 days to complete and return it back to CQC. However, the provider never completed and returned PIR form. CQC uses information received via PIR forms for monitoring purposes.

The registered manager fostered positive relationships with both staff and people using the service, as well as their families. Staff described the registered manager as approachable and receptive, making it easy to discuss any concerns. Overall, staff expressed satisfaction with the support from management.

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

The service had a whistleblowing policy which gave guidance to staff about who they could speak to should they have any concerns.

Staff reported feeling confident to speak openly and raise any concerns with the management team.

Relatives also told us they would feel comfortable approaching staff or management if they had any concerns about the service. The provider conducted surveys which gave people and their relatives using the service the opportunity to provide feedback on the running of the service.

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 provider had a policy in place on equality and diversity to guide practice in this area. Staff told us they were treated fairly by their employer. Staff recruitment was carried out in line with good practice.

The registered manager actively encouraged staff to participate in how the service was run. There were regular staff meetings held where staff could raise concerns, discuss issues, and share suggestions for improvement.

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

Robust good governance systems were not in place to ensure management had oversight of the service.

Systems were not always effective in assessing, identifying and managing risks to people. People’s medicines were not always managed safely. The provider had failed to identify information was not up to date.

The systems to identify any potential environmental hazards in the service and put measures in place to mitigate those risks were not effective. The provider’s governance systems had not identified potential risks to people.

Audits failed to identify shortfalls concerning medicines management, food hygiene and to protect people’s rights under MCA 2005.

People did not always receive personalised care that was responsive to their health care needs.

Policies lacked details of relevant nominated individuals and also were not updated with current working practices within the care home.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement

The provider did not always referred people to healthcare professionals when they needed.

Healthcare professionals such as social workers we contacted shared positive experiences working with the provider. Comments from healthcare professionals included, “From my observations and professional interactions with the service, I have experienced a positive working relationship with Ebenezer residential care home.” “The home has consistently worked collaboratively with professionals and has shown a genuine commitment to promoting residents' well-being, safety, and quality of life.” “The registered manager has been very approachable, always available when required for information or reviews and assessments and communication has been very good.”

The provider was also working closely with National Care Association and Care Provider Alliances to keep up with industry updates, trainings and for advice.

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.

During our inspection, the deputy manager and nominated individual both were receptive, keen to learn and improve service. The provider acknowledged our recommendations and started working to address the issues we raised during our assessment. For example, we found the issue around food not being labelled. On our second visit, all the food in the fridge was labelled. Medicines audit was carried out, and issues we identified were addressed. The nominated individual planned to carry out staff medicine competencies assessment for all staff administering medicines to people.

The provider also working closely with National Care Association and Care Provider Alliances to get specialised advice and to improve their services.