Archived: Ebury Home

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

This is the first assessment for this service. This key question has been rated Inadequate.

This meant people were not treated with compassion and there were breaches of dignity; staff caring attitudes had significant shortfalls.

The service was in breach of legal regulation in relation to person-centred care.

This service scored 25 (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 treat people with kindness, empathy and compassion, or respect their privacy and dignity. Staff did not treat colleagues from other organisations with kindness and respect.

Staff lacked kindness and compassion when supporting people during moving and handling processes. One person had been observed to be in distress and staff had not identified this at the time of the procedure. This left the person exposed to further risk of harm.

People were not supported by staff to maintain their personal appearance or dignity. For example, multiple people were observed to be unclean, unkempt, and with ingrained dirt under their fingernails. Multiple bedrooms we sampled had dry, unused toothbrushes next to people’s sinks. This left all people exposed to the risk of harm from poor personal care practices.

The provider did not treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. The provider did not take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

People were not treated with respect, as individuals, with rich life histories. Staff were entirely task-focussed and often the only interaction with people was during a personal care or moving and handling event.

People were observed to have reduced social interaction with staff during our time at the service. This left people at risk of social isolation.

The provider did not promote people’s independence, so people did not know their rights and have choice and control over their own care, treatment and wellbeing.

People had a limited choice of opportunities within the service to maintain their independence, as time with staff was mainly restricted to providing personal care tasks. All people living at the service were found to be sitting in the lounge area, sleeping intermittently throughout both days of our visit. There was little meaningful occupation and the majority of contact with staff was given when people required personal care or moving from the room to another area. There was no activities coordinator or structured activity diary in place for people. People who could speak with us, told us they were bored.

There was a lack of clear guidance in place for staff, to enable them to support people to be as independent as possible. People were not supported to understand their rights by using different ways to communicate.

The provider did not listen to or understand people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

During our site visits, we observed multiple occasions where people exhibited distress, or asked for help and were ignored. For example, one person was found by an inspector, in a communal corridor, slumped on the floor. The person had no way of alerting staff to their needs. The inspector intervened, to ensure the person was clinically checked by the nurse in charge. However, the records and follow up observations were inaccurately documented. This left the person exposed to the risk of further deterioration. The inspection team requested the deputy manager sought emergency healthcare for this person, who was subsequently transported to hospital for further investigation.

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. For example, where a person had experienced a recent fall or weight loss, this had not been clearly documented in their risk management plan.

Staff kept minimal records on how they had supported people and at what time. These records were split over several recording formats and were not being collated or audited regularly by the registered manager. This meant changes in a person’s needs were not promptly identified, nor improvements made to their planned care.

The provider did not care about or promote the wellbeing of their staff. They did not support or enable staff to deliver person-centred care.

Staff we spoke with did not feel valued by the provider and there was low morale among the workforce. Staff were not enabled to drive or shape improvements at the service and felt disempowered. Staff felt uncertain about the stability of their roles and the future of the service.