CQC report explained · a residential care home
What the CQC found at Ebor Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Medicines were stored, given and recorded safely. Risks were assessed, although inspectors said bathrooms needed closer attention to remain clean and hygienic at all times.
- Effective?
- Good
- The home was working within the Mental Capacity Act and had submitted required Deprivation of Liberty Safeguards applications. Staff training was mostly up to date, but work to update all staff supervisions was still continuing.
- Caring?
- Good
- People were treated with respect, privacy and dignity. Inspectors observed warm and patient interactions, although they noted two occasions where language used by a staff member was patronising.
- Responsive?
- Good
- Care plans described people's needs and preferences and were reviewed monthly. Activities and end of life care were available, but there were periods with limited stimulation and some people were unsure how to make a complaint.
- Well-led?
- Requires improvement
- The new manager and provider had improved medicines, recruitment, legal safeguards and quality checks. However, records, staff supervision, cleaning, laundry and the new electronic care system still needed further work and consistent use.
What inspectors found, April 2018
Rated Good overall, but well-led Requires Improvement because recent improvements still need to become consistent and lasting.
Inspectors visited the home without notice on 7 and 15 February 2018. They spoke with people, relatives, staff and healthcare professionals. They reviewed care records, recruitment files, training records and quality checks, and observed care.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found medicines were managed safely, recruitment checks had improved, people were treated with kindness and respect, and care plans and activities were in place.
The home was rated Requires Improvement for Well-led. The manager and provider had made important improvements, but some systems were still new. Inspectors wanted more evidence that improvements would be consistent and lasting.
The home had previously been rated Requires Improvement at four inspections. At this inspection, it was meeting all legal requirements and was no longer in breach of regulations.
Safer medicines
Medicines were in stock, stored correctly and recorded properly. Senior staff checked records every shift to identify possible errors or missed doses.
“All required medicines were in stock when we visited and medication administration records (MARs) were appropriately completed to show that people had received their medicines as prescribed.” from the report
Improved recruitment
The provider had corrected earlier recruitment problems. New staff had the required application, interview, reference and DBS checks before working with people.
“DBS checks were conducted prior to them working with people.” from the report
Kind and respectful care
People and relatives generally described staff as caring. Inspectors saw staff speaking warmly, offering choices and protecting people's privacy and dignity.
“We observed staff were respectful and friendly towards people throughout our inspection, and spoke to people in an affectionate manner.” from the report
Support with health and nutrition
People were supported to access healthcare and received suitable food and drink. Staff monitored weight and sought specialist advice when needed.
“People received appropriate support with their nutrition and hydration needs.” from the report
Complaints were investigated
The home had investigated concerns and complaints received since the previous inspection. Responses and actions were recorded, with learning shared where appropriate.
“These had been appropriately investigated and a response given to the complainant.” from the report
Leadership still developing
needs fixingMany improvements were recent, so inspectors could not yet see enough evidence of consistent, sustained progress. Some audits did not clearly show whether actions had been completed.
“Many of the improvements made since our last inspection were relatively recent, and further time was required to demonstrate consistent and sustained progress.” from the report
Cleaning and laundry
needs fixingOne bathroom was dirty for most of the morning on the first inspection day. Inspectors also said cleaning and laundry arrangements still needed improvement.
“Greater vigilance was required to ensure all bathrooms were maintained in a clean and hygienic state.” from the report
Care monitoring records
needs fixingOne person's required hourly night checks had been entered as two-hourly checks on the new electronic system. The provider corrected this and checked the other records during the inspection.
“The person's care plan stated they required hourly night checks, but the computer system was set to prompt staff to complete two hourly checks.” from the report
Activities and stimulation
minorActivities were available, but there were periods when people had little stimulation apart from television and radio. Some people said quizzes happened less often than before.
“We did note though there were some periods of the day when there was limited stimulation, other than television and radio.” from the report
Staff consistency
minorThere were mixed views about staffing. Agency staff helped maintain staffing levels, but some people and staff said agency workers did not always know people's needs well.
“There was still some staffing inconsistency and staff who didn't know people's needs as well.” from the report
- 01How do you now check that medicines rounds are not interrupted or affected by distractions?
- 02How are you making sure all staff supervisions remain up to date?
- 03What changes have you made to keep every bathroom clean and to improve the laundry service?
- 04How do you check that electronic care records match each person's care plan, including night-time checks?
- 05What activities are now available during periods when people might otherwise have limited stimulation?
This was a full comprehensive inspection covering all five key questions and all aspects of the home, with the previous ratings checked again. This explanation was written from the published report of 19 April 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2017
Requires Improvement overall; well-led was rated Inadequate, with caring and responsive care but repeated safety and governance failures.
Inspectors carried out an unannounced comprehensive inspection over 17, 18 and 20 July 2017. They spoke with people, relatives, staff and healthcare professionals, reviewed care and recruitment records, and observed care in the home.
They found kind and respectful care, choices were respected, and people could take part in activities. Staff numbers had improved and people generally received suitable support with food, drink and healthcare.
However, some medicines ran out, recruitment checks were incomplete before some staff started, and some DoLS applications had not been submitted. Quality checks did not reliably identify or fix problems, and there had been repeated changes in management. The home was rated Requires Improvement overall, with Well-led rated Inadequate.
Choices and dignity
People were involved in everyday decisions, including what to eat, when to get up and whether to join activities. Staff respected privacy and dignity.
“We observed people's choices were respected, such as what people wanted to eat and drink, where they wished to sit and whether they wanted to join in activities.” from the report
Activities and visitors
People could join activities such as exercise classes, crafts, trips and games. Families and friends were made welcome.
“People spoke positively about the activities they took part in and people's family and friends were made welcome at the home.” from the report
Medicines ran out
seriousOne person's medicine was unavailable from 17 to 19 July because it had not been ordered in time. Inspectors said this problem had appeared at previous inspections and had returned.
“They had not received their medicines on 17, 18 or 19 July 2017.” from the report
Incomplete recruitment checks
seriousThree of four recruitment files showed staff had started training or shadowing before full DBS checks had returned. A reference issue had also not been fully recorded or explored in the file.
“This meant there was a lack of evidence that only people considered suitable to work with people who may be vulnerable had been employed.” from the report
Weak management oversight
seriousThere had been no registered manager for over 12 months, with several managers leaving and acting arrangements in between. The provider had not shown sustained improvement after earlier inspections.
“There was no registered manager in post on the day of our inspection and, as such, the registered provider was not meeting the conditions of their registration.” from the report
Audits did not drive improvement
needs fixingSome audits were missed, and actions were not always signed off or checked by senior managers. Audits failed to identify the recruitment, medicines and DoLS problems found by inspectors.
“This showed the audits were not being consistently effective in driving improvement to practice.” from the report
DoLS applications delayed
needs fixingSeven people had been identified as needing DoLS authorisation, but applications had not been submitted when inspectors visited. The provider said these were submitted the day after the inspection.
“The provider did, however, confirm that seven people had been identified as requiring a DoLS authorisation for whom an application had not yet been submitted.” from the report
- 01What systems are now in place to make sure nobody runs out of prescribed medicines?
- 02Are all DBS checks, references and other recruitment checks completed and recorded before staff work unsupervised?
- 03Who is the registered manager now, and when was their registration with the CQC completed?
- 04How are quality audits checked to make sure every action is completed and signed off?
- 05Have all required DoLS applications been submitted, and how are their renewal dates monitored?
This was an unannounced full comprehensive rated inspection covering all five questions, brought forward because the CQC had received information of concern. This explanation was written from the published report of 19 September 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Ebor Court
5 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- April 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2015
Registered with the Care Quality Commission on 10 November 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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37 live-in carers within about an hour of York
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,270 a week. 32 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.