Archived: Ebury Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to leadership and 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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The registered manager staff did not involve people, relatives or staff in the shaping of the service. There was no service improvement plan in place to track developments and ensure required measures were taken to maintain the service to a safe standard.

The provider had failed to ensure effective systems were in place to promote a positive culture of transparency, learning and improvement. The provider failed to have systems and processes to ensure people and their representatives were engaged and involved in the arrangements of their care and treatment and to the improvements of the service. The provider failed to have processes to ensure that staff supervisions, team meetings and residents’ meetings were held regularly, and were meaningful and effective.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The service lacked strong, effective leadership to enable the required improvement measures to be made. This left people with poor outcomes and a poor lived experience.

People and their relatives did not feel they could speak up and that their voice would be heard.

The complaints process in the service was ineffective. This meant the provider failed to analyse or have robust oversight of themes and trends in complaints and concerns. The provider could not demonstrate how they would prevent similar issues from happening again. The process for induction and supervision of staff was in place, however not all staff had received regular supervision, including the registered manager.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider showed a lack of knowledge and understanding of workforce equality, diversity and inclusion. We reviewed recruitment records where staff had been asked about their personal responsibilities prior to being offered employment. The provider did not consider that this approach could be seen as discriminatory.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The registered manager was unable to show us any lessons learned, or improvements implemented as a result of any incidents that occurred. The registered manager had failed to report notifiable incidents to the CQC or local authority as required by law because the manager was unaware of these requirements. Feedback from staff did not provide assurance or evidence of robust and effective, governance and oversight systems.

The provider failed to ensure its systems and processes were in place and effective. There was no accident and incident or behaviour chart audits in place. This meant the provider did not have the systems to identify themes and trends to inform them how to improve support and safety for people. There were no provider audits of care and this left the service without effective oversight, leaving people at risk of having unmet needs.

There was no evidence of call bell audits that had been completed by the management team, to assess the response from staff or where risk to people required review. The registered manager advised us they had ‘no way’ of carrying out this analysis at the present time. This left people exposed to a risk of harm, due to their needs not being met.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Feedback from the commissioners and the local authority was negative in regard to the way the service worked in partnership with them, and had failed to seek and implement advice and guidance where it was needed. This impacted on the care experience received by people, and left them at risk of harm.

The systems in place had failed to ensure professional input was sourced in a timely manner to improve outcomes for people. People who were at high risk of falls had not had referrals made on their behalf to support risk mitigation. External health team information regarding diabetes and nutrition support management was not included in people’s care plans, leaving them at risk of further harm.

Contact with relatives was not always recorded. Incident records, such as falls records, did not consistently include information about whether relatives had been contacted about the incident and any subsequent actions taken. The registered manager had failed to ensure their duty of candour was being followed.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There were significant and widespread concerns identified during this assessment. The provider failed to evidence that any action had been taken to learn and improve the quality of the service. The provider had failed to implement a consistent approach to measure outcomes or monitor the impact and quality of care for people. The lack of systems to monitor risks and to mitigate health and safety requirements put people at risk of harm.

The provider did not demonstrate a focus on continuous learning and improvement across the service. The provider failed to have systems in place to deliver a quality experience, positive outcomes and good quality of life for people. The provider had failed to improve the living environment for people and had given no regard towards people’s care and safety. This left people exposed to the risk of significant harm.