Queen Elizabeth House

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

The last rating for this key question was 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, including the management of people’s medicines.

This service scored 59 (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 proactive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated when required ensuring safety events were appropriately reported and managed. Lessons were learnt through daily staff meeting and staff supervision to continually identify and embed good practice.

There were policies and procedures in place for responding to incidents, accidents and complaints and staff were knowledgeable about these. Staff meetings were held providing opportunities for effective communication and to share updates and any learning. However, the provider was in the process of transferring all paper records on to a new electronic system which would enable the registered manager and staff to have an overview of accidents, incidents and safeguarding to promote learning. Records showed that following events, changes were made where required to address them.

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

Assessments of people’s needs and wishes were completed upon admission to the service. However, these were not always reviewed on a regular basis to ensure they were reflective of people’s needs. People told us if they required support from a health care professional, this was arranged promptly by staff. A person told us, “The doctor is here once a week but if we need to see someone sooner, they [staff] will arrange it.”

Staff worked effectively with health and social care professionals to ensure people received appropriate support when meeting their physical and mental health needs.

Staff worked with people and health and social care professional to understand what being safe meant to them and the best way to achieve that. Staff focused on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff shared concerns appropriately ensuring people’s safety and well-being.

People told us they felt safe with the staff that supported them. Comments included, “This is a wonderful home, and I feel quite safe”, “If they [staff] are with me, I have total confidence”, and “I have got to know most [staff] quite well and have got complete confidence.” A relative told us, “The staff have a wonderful attitude, and I observe that [loved one] trusts them.”

There were safeguarding policies and procedures in place and staff were trained to recognise and respond to concerns, potential abuse and harm. Staff told us they felt confident any concerns would be managed appropriately. A staff member told us, “I would report any concerns I had to the senior on duty or registered manager. I would report my concerns to the local authority safeguarding team and the CQC if I felt I needed to.”

There were systems in place to ensure oversight of all safeguarding concerns and accidents and incidents. The registered manager showed us the providers electronic system used to manage these. Records showed that appropriate actions were taken by staff where required.

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a deprivation of liberty safeguard (DoLS) authorisation was applied for through the relevant local authority and we saw that any conditions within them were met.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People told us they were involved in planning and managing their needs and risks. A person said, “Yes, I am but I haven’t changed much.” A relative commented, “They [staff] are very health and safety conscious.” A staff member told us they followed people’s care plans where they were at high risk of falls, and said people at risk of falls were always supervised. Another staff member told us how they supported a person at risk of choking by making sure they had a soft diet and thickened drinks.

Despite positive feedback, risks to people were not always assessed and documented within their care plans. The registered manager told us they were in the process of transferring all paper-based care plans and care records on to the providers new electronic care planning system. This transition started in October 2025 and was due to be completed in the new year. In this instance we looked at both paper and electronic care plans to ensure information and risks were appropriately assessed for people using the service.

3 care plans we looked at documented standard text generated from the electronic care planning system that did not reflect individuals’ needs and risks. A communication plan for one person listed potential risks. However, there were no documented strategies and guidance for staff on how to address the risks identified. Risks and risk management guidance was also not documented within the persons cognition plan. A healthcare professional had documented the person had a diagnosis of unspecified dementia. There was no falls risk assessment or care plan in place to manage and mitigate this. Another person who was an insulin-dependent diabetic had a diabetes care plan in place. However, this required greater detail of the persons specific symptoms related to hypoglycaemia (low blood sugar) and hyperglycaemia (high blood sugar), including how these were recognised, managed, and when staff should seek medical assistance. Another person required a two-hourly turning regime to minimise the risk of pressure areas. However, turning charts showed several disparities in the records showing significant time gaps between turns, for example, 02:24 to 06:00 meaning 3 hours 36 minutes gap, raising concern for pressure area care. A fourth persons care records and plans were incomplete and there were no care plans in place for areas including cognition, mental health and emotional well-being, mobility, nutrition and hydration, mental capacity and personal care.

We found no evidence that people had been harmed, however, care records failed to demonstrate that risks to people were safely managed. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. Equipment was regularly serviced to maintain safety.

The design of the premises was meeting people's needs. Comments from people and their relatives about the environment included, “The home is a truly wonderful home, spotless, and I am grateful to be here”, “It is a lovely environment and always clean”, and “It is lovely and very comfortable.” The service had adapted bathrooms, dining room, and quiet areas with suitable furniture to support people with limited mobility. There was a garden area at the rear of the service with suitable furniture for people to use in warmer weather.

The provider detected and controlled potential risks in the care environment. The maintenance person had assessed and maintained the environment and equipment used. We saw servicing records for the fire alarm system, portable appliances, gas safety and legionella testing. Checks and audits were also carried out on hoisting equipment, wheelchairs, baths, window restrictors, the call bell system and regular fire drills were conducted. The fire alarm system was tested every week.

The kitchen was clean and well maintained. We saw food was stored safely and hygienically and food that had been opened had been labelled with the date of opening. The kitchen had received a food hygiene rating of 5 from the Food Standards Agency.

The provider made sure there were qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide care that met people’s individual needs.

Staffing levels at the service appeared minimal. The registered manager told us they used a dependency tool to work out the number of staff required to meet people’s care and support needs. The current staffing levels were 1 senior care staff and 3 care staff on duty during the day with 1 senior care staff and 2 care staff at night.

People and their relatives’ views about staffing levels were mixed. Comments from people included, “Yes, there are enough staff”, “I feel that they [staff] are very short staffed, you hear the bell at night, and answer timing varies”, “I think they [staff] could do with a few more staff, but they do come quickly if I need them”, and “They [staff] could do with more staff; they work far too hard.” A relative commented, “I think there are enough staff, there is always someone available.”

A staff member told us, “The staffing levels are not leaving people at risk as we monitor our sections of the service. There are a lot of things to do so we could do with one more staff member, at the moment we are coping. The new care planning system is giving staff more time with the residents.” Another staff member said, “I don’t really think there is enough staff, most people here need help, we are trying our best.” A third staff member commented, “I think we have enough staff to meet people’s needs.”

We observed how staff supported people throughout the day. At lunch time we saw there were two staff member supporting 15 people with their meals in the dining room. One member of staff offered limited assistance during this period and was seen coming to and from the kitchen. After lunch we observed the same staff member in the lounge who supervised most of the people using the service who were enjoying a birthday party and an entertainer. We asked the staff member if there was a staff member we could speak with, they told us 1 staff member had taken a person to a health appointment, another was having their break, and the other staff member was busy.

We recommend that the provider reviews their current staffing level arrangements at the service. The current staffing levels appeared stretched and could potentially leave people at risk of not receiving their care promptly and at risk in the event of an emergency.

The staff training matrix indicated that staff had completed training in areas such as fire safety, infection control, food hygiene, moving and handling, falls prevention, safeguarding adults, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Records showed that staff received formal supervision sessions with their line managers. A staff member told us, “We have lots of face to face and eLearning training. This week we will be training on infection control and medicines. I think we are very well trained.”

Robust recruitment procedures were in place. Recruitment records included proof of the staff members identification, application forms with employment histories, employment references, occupational health and right to work in the UK checks. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

There were systems in place to help prevent and control infections. We observed the service looked clean throughout. The provider had an up-to-date infection control policy, and we saw infection control audits were regularly carried out. We spoke with a domestic member of staff. They told us there were 2 domestic staff that cover the service 7 days each week. They used a cleaning schedule to make sure the service was clean and well maintained.

Staff were provided with personal protective equipment (PPE) when needed. We saw they wore this appropriately. Training records confirmed that all staff had received training on infection control.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People told us they received their medicines timely and as prescribed. Comments included, “I get my medicines at the same time every day and I check my tablets so there are no problems”, “I believe they are given correctly.”

One person required their medicines to be covertly administered. This means giving medicines in a disguised form without the knowledge or consent of the person receiving them. It may involve hiding medicines in food or drink. We asked staff to see the person’s covert medicines guidance/protocol. Staff were unable to explain or locate the guidance. While there were policies in place for covert administration of medicines available, staff lacked knowledge and were unable to produce the relevant guidance and documentation when requested.

PRN (as required) medication protocols were in place for people who required them. However, staff did not readily know where to find them. Staff had a lack of understanding of PRN medicines guidance and could not clearly explain what PRN guidance involved, nor could they easily access the information.

We looked at the Medication Administration Records (MARs) for 11 people. We saw that there were a number of gaps identified where the reason for omission had not been recorded. For 1 person their medicine stock should have totalled 27. However, records reflected 26. Another person medicines count was 156, but we found there were 152, leaving 4 tablets unaccounted for. Staff believe these medicines may have been administered but not signed for. This required improvement to address discrepancies in medicine administration records and data entry accuracy.

Staff managing and administering medicines had not had their competencies assessed in person. Competencies were conducted through online training. Best practice guidance and medicines management regulations specify that online medicines training alone is not sufficient. They emphasize that care home staff must be both trained and assessed as competent to safely handle medicines. All staff responsible for administering medicines should receive appropriate training, with competency checks completed annually. The registered manager confirmed that staff had completed online training, but there were no competency checklists available, or competency assessments conducted.

Medicines were stored securely in locked cabinets and medication trolleys. Controlled drugs were held in a separate locked cabinet with restricted access, in line with legal requirements. However, excess medicines were stored within a cupboard on first floor. This was cluttered with paper files, and the temperature of room was not checked and monitored nor recorded to ensure medicines were safe for use. Medicines audits were conducted monthly. We looked at the audit conducted in November 25. The audit and our findings highlighted a need for improved staff training including competency assessments, access to clear guidance and protocols, and robust systems for the monitoring, administration and storage of medicines.

We found no evidence that people had been harmed, however, the provider failed to ensure the safe management and administration of medicines. This was a further breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.