During an assessment under our new approach
Date of visits: 17 November 2025 and a subsequent visit to assess the provider response to our urgent concerns, on 1 December 2025.
The service was a care home with nursing, providing support to older people, some of whom lived with dementia and physical disabilities. At the time of our assessment, there were 20 people being supported with their care needs. The service was registered to support a maximum of 46 people.
The provider failed to have sufficient systems and processes to assess, monitor and mitigate the health, safety and quality of the service. Their quality assurance systems failed to identify people were at risk of harm from lack of risk assessments, plans to mitigate risks and lack of adherence to policies and procedures.
The registered manager and staff did not understand their roles to safeguard people. Incidents of alleged abuse were not recorded or reported to the local safeguarding authority.
Safety risks to people were poorly managed, which left people at risk of harm. The registered manager had not assessed and reviewed safety risks to people and involved people and those close to them in making decisions about how they wished to be supported to stay safe.
There were insufficient staff to support people with their identified needs. The registered manager had failed to review and deploy correct staffing levels regularly to ensure there were always enough suitably skilled and experienced staff on duty. Staff had not received all relevant training to meet the range of people’s needs at the service, for example, manual handling of people and the use of specific equipment to support with this.
People’s needs were not clearly documented in their care plans, so staff lacked clear guidance on all of a person’s mental, physical and social needs. This left staff with gaps in information on how to support people to manage risk and provide effective, safe support.
People were not fully aware of their rights around care and treatment. Staff lacked knowledge of the mental capacity act, including capacity and consent.
People’s nutrition and hydration needs were not supported in line with current standards. Where people lived with clinical conditions which required effective nutritional support, records showed this was not provided, monitored or escalated when required.
During our assessment, we found significant concerns, which resulted in breaches of Regulation 9 (Person-centred care), Regulation 10 (Dignity), Regulation 11 (Consent), Regulation 12 (Safe Care and Treatment), Regulation 13 (Safeguarding), Regulation 17 (Governance) and Regulation 18 (Staffing).
We served a notice of decision to Ebury Home Limited on 20 November 2025 to impose conditions on their registration as a service provider in respect of the regulated activity Accommodation for persons who require nursing or personal care. Namely, ‘That the registered provider must not accept any new packages of care without prior written agreement of the Care Quality Commission at Ebury Care Home.'
We received subsequent information of concern, from external partner agencies, that people remained at significant risk of harm and abuse.
We served a subsequent notice of decision to urgently suspend the registered provider of Ebury Home Limited on 3 December 2025. The provider de-registered following this and is no longer providing a regulated activity from the location. The care home is closed.