Elizabeth House

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 inspection we rated this key question good. At this inspection 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 provider was in breach of the legal regulation relating to good governance.

This service scored 61 (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 a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff spoke positively about working at the service and felt well supported in their roles.

The registered manager told us about their values which included people’s needs were met safely, staff were well trained to do their jobs, to be open honest and approachable to people and their families, and to ensure everyone has a great quality of life. However, we did not see how these values were shared to ensure staff were aware of them and the providers expectations in relation to these.

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

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge and experience to lead effectively.

It was not always clear what level of support the registered manager received for their own development and how they were being supported to implement changes in the service. Furthermore, there was a lack of monitoring of senior staff members who undertook checks within the service. Throughout our inspection we highlighted areas where improvements and changes were required, the registered manager took our feedback seriously and evidenced plans to improve and the immediate action taken where needed. The registered manager was transparent throughout the inspection process and showed a desire to make improvements where concerns were identified.

The registered manager told us they felt supported in their role and spoke of developing an inclusive workforce.

Staff told us leaders were visible and gave them support and guidance as well as demonstrating a caring attitude towards them. Staff told us they had meetings with management staff and had opportunities to discuss the service and their own development. One staff member told us, “The manager is always available for the staff and provides guidance.”

People, their families and staff knew who the management team were, and how to contact them. People and relatives told us the management team were caring and approachable. One relative told us, “The manager is very approachable but to be honest I've never had a problem with anything.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People told us they felt confident to speak with staff or the registered manager if they had any concerns. Nobody we had spoken with had any concerns to share. One relative told us, “We’ve not had any complaints. If we did have a complaint, I’d just tell them; I'd speak to the manager.”

Staff felt confident to raise any issues or concerns with the management team if needed and were confident action would be taken. One staff member told us, “The manager is very approachable, we can raise any issues.”

Information about policies to support a culture of speaking up such as whistleblowing and complaints were available within the home although most people we spoke with were not aware or did not recall being made aware of a complaints policy.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt included in decisions about the service and spoke positively of the provider.

The registered manager worked closely with staff to ensure there was no bias in everyday practice and to ensure they worked in accordance with the providers policies and procedures. They confirmed they were flexible to staff working arrangements when needed to support staff to carry out their roles effectively.

The provider had policies in place to support equality and diversity in the workplace. Staff had access to these policies on an electronic system.

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

We found concerns in relation to governance; the provider’s audits were not sufficiently detailed to ensure a robust system of oversight was staking place and had failed to identify the concerns we found at this inspection. For example, we found care plan audits were being completed by senior care staff however they did not identify that several records were not accurate or had missing information. This meant the audits were not always effective. The registered manager told us they did not have an oversight of the audits completed by the senior care staff. The registered manager confirmed going forward they would conduct an audit of the care records audits being completed by staff.

In addition, audits of people’s care did not always identify when referrals to other health and social care professionals had not been made or did not include sufficient information about their needs and risks. This meant some people were at risk of not having their care needs met.

For example, we found some people were registered with the local dentist, however there was no record of any dental appointments taking place or any guidance regarding their oral health.

Furthermore, we found issues in relation to the provider’s policies. The provider’s policies were not consistently reviewed to ensure they were up to date. For example, the supervision policy’s review date had passed, and a review did not take place. The health and safety policy, Infection Control Policy Procedure and the Whistleblowing Policy had no start date and no review date. This meant that that staff may be following outdated or incomplete guidance, which could lead to inconsistent practice, reduced safety for people using the service, and a lack of accountability if issues arise.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People’s needs were assessed prior to moving into the service to ensure the service could meet people’s needs safely. Referrals to health and social care professionals were made when appropriate to manage any risks identified. Records demonstrated improvements in people’s health such as cleared infections and healed skin conditions.

Staff understood the importance of sharing information with health professionals to ensure they received the right care to support their health and wellbeing.

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

The provider had worked closely with commissioners to improve the quality of care delivered and at the time of the inspection were working through an action plan with the local authority. However, improvements were still required the management and oversight of care planning, assessing people’s needs, supporting people with their risks to ensure people consistently received safe and effective care, and positive outcomes. There were significant gaps in the processes for recording, reviewing, and investigating accidents and incidents. The analysis of these events needed to be more robust, including identifying patterns and implementing preventive measures. Additionally, the provider did not demonstrate that lessons learned were shared or that risk assessments and care plans were updated to reflect these findings.