The Care Quality Commission
  • Mental Health
  • Independent mental health service

Elizabeth House

Overall: Good read more about inspection ratings

Perth Avenue, Leicester, Leicestershire, LE3 6QR (0116) 507 1840

Provided and run by:
Plans4Rehab Limited

All Inspections

During an assessment of Acute wards for adults of working age and psychiatric intensive care units

This assessment for acute wards for adults of working age provided at Elizabeth House took place in September and October 2025.

Elizabeth House is a hospital based in Leicester and can accommodate up to 30 people who are experiencing an acute episode of mental illness and require an admission to hospital for assessment, treatment and stabilisation. Patients may be informal or detained under the Mental Health Act (1983).

The hospital has 30 beds over three wards:

  • King ward – accommodates up to 15 males
  • Castle ward – accommodates up to 10 females
  • Swithland ward – accommodates up to 5 patients, males or females, depending upon the need for referrals received.

At the time of our assessment, King and Castle wards were open.

The hospital is registered to provider the following activities:

  • Treatment of disease, disorder or injury
  • Assessment or medical treatment for person’s detained under the Mental Health Act 1983.

There was a registered manager in place at the time of this assessment.

At our last assessment the provider had been in breach of Regulation 9: Person Centred Care; Regulation 12: Safe Care and Treatment; Regulation 17: Good Governance; Regulation 11: Need for Consent and Regulation 18: Staffing.

At this assessment we did not identify any breaches under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We rated this hospital as good.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. The service had a full time Mental Health Act administrator who ensured all patients were detained legally. They maintained oversight of all detention documentation to ensure staff adhered to the Mental Health Act Code of Practice. During office hours, the Mental Health Act administrator scrutinised all relevant documentation for new patients detained under the Act. Out of hours, this responsibility was passed to the nurse in charge. Comprehensive checklists for receiving detention papers were available in the nursing offices for staff to refer too.

Staff explained to each patient their rights under the Mental Health Act in a way that they could understand, repeated as necessary and recorded it clearly in the patient’s notes each time. Information about patients’ rights under the Mental Health Act were displayed in ward areas on notice boards. Staff made sure patients could take section 17 leave (permission to leave the hospital) when this had been agreed with the Responsible Clinician.

Patients had access to independent mental health advocacy. The hospital worked with a provider and made regular referrals to ensure patients were supported. Advocates visited the hospital regularly and attended MDT meetings and managers hearings upon request.

For patients detained under the Mental Health Act, responsible clinicians had completed the appropriate statutory certificates authorising treatment. Second opinion appointed doctors (SOAD’s) authorised treatment when patients lacked capacity to consent. The responsible clinicians explained this process to patients. The electronic notes system had an alert which notified the user when consent to treatment was due.

The service had relevant policies and procedures in place relating to the Mental Health Act (1983), with easy access to the Code of Practice. Staff received and kept up to date with training in the Mental Health Act, which was mandatory for all care staff. At time of assessment, compliance was 100%. The Mental Health Act administrator regularly audited documentation relating to the Mental Health Act to ensure best practice was followed.

Mental Capacity Act

Staff supported patients to make decisions around their care and treatment. Staff assumed capacity, in line with the Mental Capacity Act 2005. Staff gave patients all possible support to make specific decisions for themselves before deciding a patient did not have the capacity to do so. When the MDT had doubts about a patient’s capacity to make a specific decision, relevant capacity assessments were completed. The service had relevant policies and procedures in place relating to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

Staff received and kept up to date with training in the Mental Capacity Act, which was mandatory for all care staff. At time of assessment, compliance was 100%. It was evident during staff interviews, that they had an awareness about the Act and the key principles.

The Mental Health Act administrator was available to offer advice regarding the Mental Capacity Act, and discussions around potential Deprivation of Liberty Safeguard applications. The Mental Health Act administrator regularly audited documentation relating to the Mental Capacity Act to ensure best practice was followed.

During an assessment of the hospital overall

We assessed Elizabeth House in September and October 2025.

Elizabeth House was registered to provide the regulated activities: Treatment of disease, disorder or injury and Assessment or medical treatment for person’s detained under the Mental Health Act 1983. The hospital had a Registered Manager in place.

The hospital can accommodate up to 30 patients across three wards:

  • King ward – accommodates up to 15 males
  • Castle ward – accommodates up to 10 females
  • Swithland ward – accommodates up to 5 patients, males or females, depending upon the need for referrals received.

We visited King and Castle wards. At the time of our assessment Swithland ward was closed.

During this assessment we assessed the service group: Acute wards for adults of working age. We assessed all 33 quality statements across the five key questions.

Our overall rating has improved from requires improvement to good.

19 and 20 December 2023

During a routine inspection

This was the first inspection of this service. We rated it as requires improvement because:

  • The ligature risk assessment was held electronically. Numerous staff had not seen this. There was no information on the wards to indicate high risk areas.
  • Not all agency staff profiles detailed mandatory training received and so we could not be assured that all agency staff were appropriately trained.
  • The service did not have an employed occupational therapist. We were concerned that patients were not receiving meaningful and therapeutic activities.
  • Staff lacked knowledge around the Mental Capacity Act despite having received training. Records of capacity were not consistently detailed.
  • Not all care plans were personalised and lacked individual goals, aims and interventions.
  • Not all patients had been involved in their care planning.
  • Some staff had difficulty accessing and navigating the electronic records system.
  • Patients could not have access to fresh air as and when they wanted. Most windows across the hospital could not be opened.
  • Governance processes needed to be strengthened to ensure ongoing monitoring of the quality of the service.

However:

  • The ward environments were safe and clean. The wards had enough nurses and doctors. They minimised the use of restrictive practices and managed medicines safely.
  • Staff developed a range of care plans which were updated regularly.
  • Managers ensured staff received training, supervision and appraisals. The ward staff worked well together as a multidisciplinary team and with those outside of the hospital who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.