Ebenezer Residential Care Home

“While people and relatives we spoke with expressed that they were happy with their care, our assessment found elements of service provision that did not meet expected standards for people using the service. We found the provider was in breach of Regulations 9, 11, 12, 15, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”

“We found that care plans did not contain sufficient detail to support the delivery of safe, effective and person-centred care. There was an inconsistent approach to risk management. Risks to people’s health and safety were not consistently assessed, and appropriate action was not always taken to mitigate identified risks. However, we found no evidence that people were harmed.”

“The service was not consistently operating in line with the principles of the Mental Capacity Act 2005 (MCA). Systems and processes for the safe management of medicines were not always effective. In addition, governance arrangements were not operating effectively to monitor, assess and drive improvements in the quality and safety of care.”

“People were not protected from the risk of abuse. Care plans and risk assessments were not updated in line with people’s current needs. However, we found no evidence people were harmed. Staff demonstrated a good understanding of how to recognise and report safeguarding concerns.”

“Robust recruitment procedures were in place to help ensure staff were suitable for their roles. Staff told us they felt supported by the management team. Leaders were open to feedback and demonstrated a commitment to continuous improvement.”

“Staff promoted independence and supported people to maintain their autonomy. People had developed positive relationships with staff and were supported by a consistent staff team who knew them well.”

“The provider did not work collaboratively with health and social care professionals to ensure people received coordinated and effective care.”

“People and relatives could raise concerns, and front‑line staff were approachable. They were confident speaking up would always lead to timely action and learning would be fully assured.”

“Systems to monitor the quality and safety of the service were in place but they were not effective as they failed to identify shortfalls and risks to people.”

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