Archived: Ebury Home

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

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

This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulations in relation to person-centred care, dignity and consent.

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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People were exposed to significant risk of harm, due to the lack of effective care planning and risk oversight of their known healthcare needs.

For example, people living with a known risk of falls had no clear guidance within their care plans, for staff to follow. Falls care plans and risk assessments for people, lacked relevance to their identified current level of mobility. Professional contact records in people’s care plans showed a lack of onward referrals to external health and social care teams to support people with equipment or for occupational therapy and physiotherapy review.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People's needs were not always documented accurately to ensure consistent support. For example, staff did not have all the relevant information about people's diabetes management; what to look out for when blood sugars were too high or too low and the relevant action to take. Staff did not have information they required to support people living with a urinary catheter. This left people exposed to the risk of significant harm, through poor care planning and support.

One relative told us, “My family member was in hospital for 3 weeks and was then discharged to here. My relative deserves better than here. They have frontotemporal lobe dementia. I would not recommend here.” We saw the care plan for this person did not detail their specific diagnosis. Staff we spoke with lacked understanding of the impact of the person’s clinical condition on their needs. This lack of understanding and poor care planning, left the person exposed to the risk of harm.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

The provider lacked clear processes for ensuring referrals were made to external partners. Staff lacked understanding on how to refer to external health and social care providers, to provide support for people in the most effective way.

We found any guidance which had been given by professionals was not clearly recorded or updated in care plans or followed effectively by staff. This left people exposed to the risk of harm from not receiving the appropriate care and support prescribed for them.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

The service failed to have robust preadmission processes in place. They did not consider if they could meet the needs of people or assess the impact of people’s needs on others already receiving the service. People’s assessments were insufficiently detailed to enable effective and safe, quality care planning. This put people at risk of their needs not being met. For example, we found a number of people who required specific diets for diabetes management. In one person’s care plan it stated the person could manage independently with a normal diet. Recording of daily intake of food and fluids for people was unclear and lacked specific detail. This left people exposed to the risk of harm.

People’s nutrition and hydration needs were not supported in line with current standards. Staff had failed to effectively identify people at risk of weight loss and monitor the food they consumed. This left people at risk of continued harm from weight loss and skin damage.

Some people at the service found it difficult to eat their food without assistance. This was due to their diagnosis of dementia. The service had not provided any alternative plating, which can encourage people living with dementia to eat meals. This left people who struggled to eat independently at risk of not maintaining a healthy intake of food and reduced their independence during dining.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

There was a lack of effective communication and co-ordination between the service and external health and social care teams. This left people with poor outcomes. For example, where people required review of equipment and this had not been actioned. This left people at risk of harm.

Referrals were not always made to external teams to help mitigate risks effectively. For example, people who had experienced falls and injuries had not always been referred to professionals for specialist input to help mitigate this risk. Where referrals had been made, these had not always been followed up in a timely manner by the service. This left people at risk of not receiving effective support.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

People had been deprived unlawfully of their liberty without their consent by the provider, who showed a lack of understanding of the principles and practice of the Mental Capacity Act 2005. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. People with capacity to be involved in their care planning and decisions around their care and treatment had not been consulted in planning or review of their care plans.

Where people lacked capacity to make decisions, their families had not been given the opportunity to inform the care and treatment in the best interests of their relative. We found the service was not always working within the principles of the MCA as some people's capacity had not been assessed and this had not been recorded in their care plans. We found that practices were not always the least restrictive and the impact of decisions made had not been assessed. For example, multiple people had sensor mats or bed rails in place in their bedrooms. There were no documents in place to assess if these measures were proportionate and in their best interests.

The registered manager acknowledged the lack of capacity assessments and told us this was something they had been addressing. However, we did not see any evidence to support this.

There were ineffective systems in place to ensure that people’s capacity was assessed and documented.