Archived: Ebury Home

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

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

This meant services were not planned or delivered in ways that met people’s needs.

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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People were not supported to have choice and control over their own care and to make decisions about their care, treatment and wellbeing. People and families were not consulted or involved in discussing care needs, associated risks, and preferences to care and treatment.

At 1pm on the first day of our visit, a person told us they had not received food or drinks since the previous evening, and this was not uncommon. We raised this with the registered manager, who ensured the person was provided with food and fluids. However, this had not been previously identified by staff or the registered manager. This left the person at significant risk of malnutrition and ill health.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

There was limited assurance given by the registered manager that people received a wraparound care experience. Documentation was ineffective and showed a lack of oversight and clear directions for staff to follow. This left people receiving a fragmented service with gaps in their care and treatment, exposing them to risk.

There was a lack of evidence that the service worked well with partners to ensure good coordination of care and support was provided for people. Information and guidance from health and social care teams had not been implemented as required, leaving people exposed to the risk of harm.

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The provider and registered manager could not explain or show evidence they provided people who use the service, their family, friends, and carers with information which was accessible, safe and secure and supported their rights and choices.

The provider had made no provision to provide information for people or staff which was tailored to their individual needs. This included no reasonable adjustments for disabled people, interpreting and translation for people who didn’t speak English as a first language and for people living with sight loss. People who had difficulty with reading, writing or using digital services were not supported with accessible information.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

People and their relatives were not routinely involved in shaping the service and their views and opinions were not sought by the provider. Records showed us people had not been encouraged to be fully involved in planning their care. We assessed this would promote a more positive experience for people if they had been included in care planning where they were able to contribute. We observed a lack of involvement and stimulation for people living at the service, which left them disempowered and unable to contribute in a meaningful way.

People were not given choices in the decoration or enhancement of their personal space within the service. We found limited evidence of personalisation in people’s bedrooms. The rooms were poorly maintained and lacked colour or stimulation for people living with dementia or any extra sensory needs. The service was not a pleasant environment for people to live in.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it.

People’s care plans did not fully reflect their physical, mental, emotional, and social needs, including those related to protected characteristics under the Equality Act. People were not always placed at the centre of their care. People told us they were not always included in discussions about their care and support arrangements. People with capacity had not all signed agreement to their plan of care.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

There was limited assurance given by the registered manager that people received a wraparound care experience. Documentation was ineffective and showed a lack of oversight and clear directions for staff to follow. This left people receiving a fragmented service with gaps in their care and treatment, exposing them to the risk of having unmet needs.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff we spoke with were not clear about people’s advanced care planning. The lack of an emergency care plan for people left people exposed to the risk of harm and not having their needs met in the event of a hospital admission or an emergency event.

We found limited evidence of this subject being discussed appropriately and documented in people’s care plans. There was unclear recording of Respect and Do Not Attempt Resuscitation documentation, which left people at risk of receiving incorrect intervention in the event of an emergency.