Archived: Ebury Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

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

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to the environment, infection prevention and control processes, people’s safe care and treatment, the way people’s medicines were managed safely, staffing and poor governance at the service.

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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

People and those important to them were not fully supported to understand safeguarding and how to raise concerns when they didn’t feel safe. When concerns had been raised, we found the registered manager had not reported these promptly to the relevant agencies to make sure timely action was taken to safeguard people from further risk.

Safety risks to people were poorly managed, leaving 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.

Where incidents had occurred, there was a lack of opportunities for staff and people to review what had happened and ensure measures were put in place to prevent re-occurrence.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Staff had limited knowledge of which health and social care professionals supported which people. Any guidance and advice provided by these professionals had not been implemented or followed by the service. This left people exposed to the risk of further harm.

The service had failed to robustly monitor people’s health conditions, to ensure timely referrals were made to other services. For example, where people had experienced weight loss, had specific dental requirements or had experienced falls with injuries.

Documentation on people’s holistic care needs was not kept up to date. If the person required a hospital admission, this documentation should go with them to the hospital. This meant hospital staff would not have clear guidance on clinical conditions and how the person liked to be supported.

Where people required external health and social care support, documentation showed that timely referrals had not been made. For example, people who had experienced recent falls with an injury but had not been referred onto an external specialist team for review of their support needs.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The registered manager had failed to report incidents promptly to the local authority and the CQC as required. The registered manager lacked understanding of their responsibility to report allegations of abuse. This was despite a clear process being in place for referral to the local authority to ensure people were kept safe.

Relatives we spoke with, prior to and during our site visits, expressed their concerns around unexplained injuries and bruising experienced by their family members. We found the registered manager had not ensured these injuries were recorded, reported or investigated. This left people exposed to the risk of significant harm and abuse. One relative we spoke with told us, “My family member’s room is cold. Other residents keep coming into the room; there were 4 in here yesterday. We have been told to lock the door, but we can’t because the lock is broken. The staff are lovely people but do leave a lot to be desired in their standards and quality. Our relative has had many falls and unexplained injuries. There has been no safeguarding’s.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a lack of clear processes in place for how to respond to an emergency. The registered manager and staff could not clearly explain the evacuation processes to follow which were in place. We reviewed these and found them to be incorrect based on the identified needs of people and the number of staff available on site at night. This left people at risk of harm in the event of an emergency such as a fire.

We saw people were not supported safely. We observed 1 person who could become distressed when being moved with equipment. We saw staff were not quick to respond to this person and offer support that reduced their distress. This meant the person was exposed to risk of harm, as their distress escalated. Staff did not follow safe moving and handling practices. For example, 1 person was observed being moved by staff in a wheelchair, with no footplates in situ. This left the person’s feet dragging along the ground and exposed them to harm. Staff had not identified this as a risk until it was raised with them by the inspectors.

Our observations raised significant concerns regarding the effective management of risks at this service.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The management team lacked any robust process for monitoring the safety of the environment. For example, the registered manager and staff team had failed to complete regular checks around the building. The building was unheated on the upper floor and had a lack of hot water in some parts, due to a heating system failure. One person we spoke with said, “I am freezing cold.” A relative told us, “My family member’s room is like a pigsty this morning. The curtains have been pulled off and are still off a week later.” Despite these concerns being raised with the registered manager to address urgently, these significant risks had failed to be resolved sufficiently, to keep people and staff safe.

The call bell system within the service was not monitored, reviewed or audited by the registered manager, to ensure staff had responded promptly when people had pressed their call bell. This left people at risk of harm, from staff not attending to them promptly when they required assistance.

Furniture, fixtures and fittings throughout the service were in a state of disrepair. For example, the vertical blinds in the communal lounge were broken with the chains and weights discarded on the floor. We raised our concerns with the registered manager that these could be a ligature risk. Despite these concerns being raised by us, we found no action had been taken to improve this when we returned on day 2.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were no clear processes in place to ensure there were enough staff. The management team did not use a calculation or dependency tool to assess how many staff were needed to meet people’s identified needs. We observed multiple people who were ignored, and did not have their needs met, due to the low staff numbers and the lack of skills of the staff team.

Staff had not received all relevant training to carry out their roles. The management team failed to ensure there was always a suitably skilled number of staff working on shift.

Safe recruitment processes were not followed. For example, previous employers had not always been contacted to give references on the suitability of the staff member. The questions used for interview did not explore staff motivation for working with vulnerable adults. Staff registered with the Nursing and Midwifery Council (NMC) did not have effective clinical mentoring to carry out their duties safely. This placed people at an increased risk of harm. Registered nurses failed to identify people whose condition had clinically deteriorated, or multiple incidents of potential abuse and neglect. This left people exposed to the risk of being supported by unsafe staff.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The home was significantly unclean, poorly maintained and unhygienic within communal spaces and people’s bedrooms, leaving people exposed to risk of harm from infection and cross contamination.

We saw any dirt or spillages in the home were not quickly resolved. For example, we saw radiators which were soiled with human excrement, which was still evident when we returned to the service the following week. This left people exposed to the risk of cross contamination through poor infection, prevention and control practices.

There was a lack of clear processes and policies, to ensure the environment was kept clean and hygienic. This meant people were not protected effectively from the risk of and spread of infection.

Staff had received training in infection control, how to put on personal protective equipment and how to keep people safe in the event of an infection outbreak. However, we observed staff not adhering to the training and guidance and disposing of used PPE in bins in communal spaces. This left people at risk of infection and cross contamination.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning or understanding their medicines.

Staff kept records of when they had given prescribed medicines. However, we saw medicines were not always given as prescribed and at the times required.

Some people required ‘as needed’ medicines like Paracetamol for occasional pain relief. However, we found the information contained in people’s medicine administration records lacked specific detail about when and how these medicines should be given. This left people at risk of harm.

Staff had received training on how to administer medicines safely. However, the management team had failed to regularly assess the staff’s competency, to ensure they were following best practice. Medicines were not correctly stored in a secure, locked area, to prevent people accessing them unsafely. This left people exposed to the risk of significant harm, through ingestion, or from not receiving their medicines as prescribed for them.

Medicine destruction kits were found to be stored in an unlocked, accessible room. These destruction kits should be stored securely, to reduce any risk of harm to people.

Staff lacked understanding of who to report medicine concerns too. For example, we found records of a person refusing their essential medicine on multiple occasions, but no actions had been taken. This left the person at risk of harm as the registered manager and staff lacked knowledge of which health professionals to contact for support.