Queen 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 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.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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.

The registered manager had clear values which were shared with the staffing team. They told us their aim for the service was to provide people with a home where they could live as independently as possible, make their own choices and feel safe with the support provided from a team that cares. A staff member told us, “We are here for the residents, this is their home; we make it feel homely for them. Most of the staff have all been here for a long time so they know people well and there is a real family atmosphere.” Information was communicated and shared effectively with staff through daily meetings and staff supervision.

The registered manager had promoted an ‘open door’ culture for people and their relatives and was transparent in their engagement with them. A person told us, “The manager and her deputy, they are very approachable.”

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There were capable and inclusive leaders. The registered manager had managed the service for 15 years. They told us senior managers visited regularly and offered support when they needed it. The registered manager was knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about and records showed the service had submitted notifications to CQC where required.

There was a 24 hour on-call number where managers could be contacted if staff needed any advice or support. Staff were positive about how the home was run and about the support they received from the manager. One staff member told us, “I am well supported, the registered managers door is always open, she listens to staff and is very supportive.” Another staff member said, “The registered manager is like a big sister to me. She always listens to our problems and tells us off when we need it. She listens to the staff, and she is fair.”

A person using the service told us, “The manager is lovely and helpful.” A relative commented, “The manager is so kind, she came to the hospital to see if she could offer my loved one appropriate care.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us there were effective systems in place for them to raise any concerns and they felt confident action would be taken if they used them.

There were systems to enable staff to speak up. We saw the minutes from recent staff meeting. Issues discussed included a date for training on infection prevention and control, medicines, staffing and key working. A staff member told us, “The team meetings are good, not all staff can attend but the meeting minutes are shared with everyone. I can voice my opinions, and I feel listened to.” Another staff member told us, “There are 11 at 11 meetings every morning for staff to raise any issues of concern, for example, if there were any falls, if there are any health appointments or if people using the service need anything.” Information about how to raise concerns was available to people, relatives and staff.

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.

The provider supported staff to feel included and treated them with equity, taking account of their individual needs. A staff member told there was a diverse staff team with staff from very different cultures and backgrounds. They told us staff were able to celebrate their cultures by bring different foods in to share with their colleagues.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

There were systems in place for monitoring and improving the quality of the service. Auditing of care records and practices were undertaken. However, the auditing systems had not always identified the issues we found around care plans, risk management, medicines management, person centred care and mental capacity. We saw that where issues were identified these were not always acted on and were repeated on subsequent audits. For example, we saw an external audit was completed of the service in March 2025 and identified areas of concern such as, staff medication training and competency and care plans not always completed and reviewed. We discussed this with the registered manager who showed us the providers Quality Improvement Plan tool which documented action to be taken to address areas requiring improvement. We noted that not all areas of concern were documented or actioned, and this required improvement.

We found no evidence that people had been harmed, however, systems in place to monitor and manage the service failed to ensure good safe service delivery. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following our assessment of the service the registered manager took appropriate actions to make improvements to the service swiftly and had a plan in place to ensure further improvements to the service were made.

The provider clearly 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.

The service worked in partnership with health and social care organisations. These included the local authority’s commissioning team, a local hospice, a GP practice, speech and language and occupational therapists, dietitians and district nurses. The registered manager told us they attended provider forums run by the local authority where they learned about and shared good practice with other care home providers. Issues discussed at a recent forum included a new standardized system used in healthcare to quickly assess a patient's condition and the risk of deterioration. The registered manager told us this tool would be used at the service.

The registered manager told us children from a local nursery visited the service every other week to meet and chat with people using the service. Students from a local college spent time with people and were due to attend the service to help people make Christmas decorations. A local school had invited 10 people using the service to their Christmas party.

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.

There were some systems in place for learning. These included regular staff meetings and supervisions. The registered manager told us they discussed learning from accidents, incidents and complaints with staff.