Queen Elizabeth Care Centre

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.

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

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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 54 (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 always have a clear and consistently embedded shared vision, strategy and culture. While some positive aspects of frontline culture were evident, this was not consistent across the service.

Observations showed limited meaningful engagement with people, with staff interactions often task-focused and people left for extended periods without stimulation or social interaction. In addition, concerns about the registered manager’s behaviour impacted the overall culture, with evidence suggesting a disconnect between leadership approach and staff experience.

There were also inconsistencies in documentation, communication and delivery of care which further indicated the service’s vision and values were not fully embedded across all areas.

However, leaders described values focused on valuing staff, maintaining discipline and promoting inclusivity through cultural activities and engagement, including celebrating international events and involving residents in community practices. Feedback from people and relatives also highlighted a caring and compassionate approach from staff, and that relationships had improved over time.

Leaders had the skills, knowledge, experience and credibility to lead effectively. However, they did not always demonstrate inclusiveness required to ensure consistent, high-quality care and a positive staff experience.

Staff feedback indicated that leadership was not consistently experienced as supportive or inclusive. Staff reported feeling undervalued, unsupported and, at times, undermined when raising concerns. There were also reports of staff feeling bullied and not respected by the registered manager, which negatively affected morale and wellbeing.

Whilst staff shared negative feedback, people who used the service and relatives spoke positively about interactions within the registered manager. They told us, “[Registered manager] is always around, they pop in and see me from time to time, they are very pleasant.” and “[Registered manager] has taken over it has gone up so much. They really are on top of things, Queen Elizabeth Care Centre has come up in the world, it’s better brighter, cleaner.”

The registered manager demonstrated knowledge of operational systems and described working closely with compliance teams, other professionals and internal processes to improve the service. There was evidence of structured leadership input, including audits, training, and efforts to develop the environment and staffing model.

The provider did not always create an open and transparent culture where staff felt safe and supported to speak up.

Some staff reported feeling unable to raise concerns due to fear of negative consequences or not being listened to. Concerns about being undermined when speaking up created a risk that issues may not be escalated effectively.

Leaders described an open-door approach, regular engagement with staff, and a culture where speaking up was encouraged and supported. Safeguarding and whistleblowing information was visible within the service and some staff said they would not hesitate to raise concerns. However, this was not consistently reflected in staff experience.

Other staff told us they felt able to raise concerns with senior leaders, however they did not feel these were always acted upon. This meant that whilst a culture of speaking up was encouraged, it was not consistently effective in ensuring staff felt their concerns led to meaningful change.

Leaders recognised the diversity of the workforce and described efforts to celebrate different cultures and support inclusion through activities and engagement. However, systems to promote equality, diversity and inclusion were not fully embedded or effective in supportive a positive workforce culture.

Several staff reported feeling undervalued, unsupported and poorly treated, which negatively impacted morale and wellbeing. There was limited evidence that reasonable adjustments or proactive support for staff needs were considered, although leaders reported that no adjustments had been required. This meant there was limited evidence that leaders were able to identify and address disparities in staff experience.

During recruitment processes, leaders ensured that applicants were asked to complete equal opportunities forms and health questionnaires, supporting fair recruitment practices. Policies were in place to support equality and provide information in different formats where required and staff were required to complete equality and diversity training.

Governance systems were in place but were not consistently effective in identifying risks, driving improvement, or ensuring safe and high-quality care.

The provider had established governance processes, including a range of audits, trackers and monitoring processes. Despite this, governance systems were not operating effectively in practice. There were widespread inconsistencies between care plans, risk assessments and recorded incidents. For example, falls were recorded without corresponding updates to care plans, and clinical risks were not consistently linked to preventative actions.

Care records contained contradictory information, including conflicting capacity assessments and unclear risk management strategies. These issues had not been identified or addressed through existing governance systems, indicating weak oversight and quality assurance.

In other areas, such as health and safety we found audits were completed in detail and where concerns were identified these were addressed. The registered manager told us in addition to audits they always spent time outside their office to observe practice. Overall, the provider relied on processes and audits without sufficient scrutiny to ensure they were effective or driving improvement.

The provider had established and maintained effective partnerships to support people’s care and wellbeing. Leaders described working collaboratively with a range of external professionals including GPs, mental health teams, physiotherapists, occupational therapists, dentists and speech and language therapists. Referrals were made appropriately, and ongoing communication supported continuity of care and management of people’s health needs. Evidence also showed that external services, such as GPs, visited regularly and that people were given choice in their healthcare arrangements. One professional told us, “Over time, we have developed an excellent working relationship with the care home management and staff, which has enabled visits to be well organised and run smoothly. We have established clear communication protocols with the manager and care team to ensure that appointments are arranged appropriately, considering each resident’s individual needs while maintaining their safety and wellbeing.”

A business continuity plan supported partnership working in the event of disruption, ensuring continued access to essential services such as pharmacy, urgent care and other professionals. These arrangements contributed to coordinated care and positive outcomes for people.

The provider demonstrated a commitment to learning and improvement, however this was not consistently embedded or effective across the service.

While systems such as audits and incident monitoring were in place, there was limited evidence that learning from these processes led to sustained improvements in care. Leaders described reviewing incidents and sharing learning with staff through supervision and meetings.

However, inspection findings showed that recurring issues were not effectively addressed. For example, inconsistencies in care planning, documentation and risk management continued despite existing oversight systems, indicating that learning was not embedded into practice. We found that root cause analyses lacked clarity and did not demonstrate how conclusions had been reached. This limited assurance that appropriate actions were identified and implemented to reduce the risk of recurrence.

Overall, opportunities to learn from feedback, incidents and audits were not consistently used to drive meaningful or sustained improvement.