Queen Elizabeth Care Centre

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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed and governance at the service.

This service scored 56 (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 had systems in place to promote a culture of safety. However, these were not consistently effective.

Staff responded appropriately to accidents and incidents, ensuring these were acted on at the time to maintain people’s safety. However, we found that the quality and consistency of investigations and root cause analyses varied. For example, following a fall, actions included encouraging the person to increase fluid intake. However, it was not clear that an assessment had been undertaken to identify and address all potential contributing factors. For another person, the root cause analysis from a shoulder injury identified the person required a risk assessment for outings from the service. However, this has not been completed or recorded within the persons care plan. Following the inspection, the registered manager has introduced an incident review process to confirm care plans have been updated following incidents where required.

Staff and leaders described sharing learning through handovers, supervision and team meetings.

The provider worked with healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had built good relationships with the local authority and health partners. Systems monitored and reviewed how people accessed care and support. Managers undertook audits, including reviewing when people were seen by professionals and monitoring events such as hospital admissions.

Information was shared during handovers each morning and evening. The registered manager undertook initial assessments of people’s needs before developing care plans. One staff member told us, “Management will tell us information after the assessment and we need to make sure we complete the important care plans like eating and drinking, moving and handling, mobility.”

Information was shared appropriately with professionals to ensure a collaborative approach.

We received positive feedback from external agencies that staff were aware of when to make referrals and contact partner agencies. One professional told us, “They listened to my views, took my feedback into account, and involved me in discussions regarding the person's care and treatment. Regular communication and updates ensured that I remained informed and able to contribute to decisions in the best interests of the person receiving care.”

The provider had systems in place to understand what being safe meant to people and the best way to achieve that. However, these were not consistently effective.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.

The provider ensured applications were monitored. However, we found an application for a DoLS authorisation had been made for a person who had capacity to make decisions about their care. This created a risk that people may be subject to unnecessary or inappropriate restrictions. The registered manager informed us they submitted applications cautiously pending formal reviews, as people’s capacity can fluctuate.

Where people required support during times of distress, care plans lacked specific details on, clear de-escalation techniques or safeguarding protocols. This meant that the provider had not fully considered the risk of harm to people, or to others in the service.

Safeguarding and whistleblowing information was visible, and leaders described an open approach to identifying and responding to concerns. People and relatives told us staff were kind and supportive, for example, one person told us, “The staff are ever so helpful and kind, they look after us well.”

The provider had systems in place to assess and manage risks, however these were not consistently effective. Care plans did not always reflect people’s current needs or the risks identified. We found instances where staff practice differed from what was documented, which created a risk that care was not always delivered in a consistent or person-centred away.

We found examples where accidents and incidents identified the need for a risk assessment, however this had not been completed. For example, a person was seen by a podiatrist and offered equipment and regular dressing for an ulcer. However, care records stated their foot was to be elevated without a dressing. Records showed the person was deemed to have capacity. However, care records did not provide assurance that the risks, benefits and potential consequences of the proposed intervention had been discussed with the person. This meant we could not be assured the person had been involved and made an informed decision to decline interventions.

Despite these concerns, there were examples where people had been involved to manage risks. We found for one person that alcohol intake and smoking were identified as risks to their health. The provider ensured the person received information from their GP to understand the impact of this decision on their health. This supported the person to make an informed decision to continue smoking and drinking alcohol, alongside engagement with professional support to reduce their intake.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular health and safety checks, audits and servicing of equipment were carried out, including fire safety checks, water temperature monitoring and Legionella controls.

Fire risk assessments were completed and identified actions had been addressed. The environment was accessible, with wide corridors and facilities designed to support people with mobility needs. Risks were identified and managed through audits and action plans. Where issues were identified, actions were recorded and followed up.

The provider had systems in place to ensure safe staffing levels, but some risks to moving people safely remained. We observed staff supporting a person using moving and handling techniques that were not in line with safe practice. This indicated inconsistencies in staff competencies and posed a potential risk to people’s safety. Managers informed us competency assessments were completed following the inspection, and training was scheduled where appropriate.

Staffing structures across the service were defined, with a mixture of nurses, care workers and support staff available on each floor. Staffing levels were planned using a dependency tool that was reviewed regularly. However, due to inconsistent information within care plans we could not be assured that people’s needs had been fully assessed, or staffing levels were planned to meet these needs.

Observations showed staff were present and responsive to people’s needs, and people generally felt there were enough staff to support them. People told us, “Yes, I think there are enough people here to look after me, and I see the same group of people, and get to know them. I'm confident they will look after me well” and “It's really very nice here. The staff are very good, and I think very well trained. Nothing is too much trouble for them.”

Recruitment checks were completed appropriately, supported by safe employment practices. Staff received induction, training and supervision relevant to their roles.

The provider had systems in place to manage infection prevention and control. However, these were not consistently effective or embedded across the service.

We found that some areas of the environment were not always maintained to an appropriate standard of cleanliness. For example, within one sluice room we found the sink was dry, which indicated this was not being used as intended for handwashing or decontamination processes. Within the same room we found equipment was not clean and there were remnants of soiled personal protective equipment (PPE) on the floor. Managers informed us environmental audits have been amended to include additional monitoring of infrequently used clinical areas.

Relatives reported that cleaning was not always thorough. They told us, “The hygiene could be better, there was [faeces] on the floor, I reported this to the cleaner who said she wasn't allowed to clean on that particular floor which seemed pretty odd to me.” We also found some bedrooms that areas under the beds had not been cleaned. These ineffective practices of hygiene put people at risk of avoidable infections.

However, staff followed some good practice, such as using PPE during care and mealtimes. The provider ensured there were PPE stations located throughout the building and undertook regular audits to ensure these items were used correctly.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Concerns were identified in relation to documentation and governance.

We found that covert medicines lacked clear records. Covert medicines refer to medicines that are administered in a disguised form, for example hidden in food or drink, when a person lacks the capacity to consent, and this is done in their best interests in line with legal and professional guidance. For example, some records did not include written advice confirming that medicines were safe to be administered covertly. We also found that some care records contained risk assessments and detailed instructions for administering each medicine, whilst others only listed the medicines to be given covertly.

Mental capacity assessments were not always decision-specific, and there was limited evidence of regular review of some medicines, including antipsychotic medicines. These issues meant medicines systems were not always robust enough to ensure safe and person-centred use. Managers informed us following the inspection they were addressing these issues in partnership with the service’s pharmacy provider and prescribing professionals.

Despite these concerns, medicines were stored and administered appropriately, and staff demonstrated knowledge and competence in medicines administration. People confirmed confidence in staff managing their medicines. One person told us, “They give me all my medicines, insulin and all that, they know what they're doing.”

Overall, while arrangements were in place to support the safe management of medicines, these were not applied consistently, and further work was required to ensure people were fully involved and records were accurate and complete.