Elizabeth House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive - this means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people’s needs were met through good organisation and delivery.

The hospital had an admissions process to ensure staff managed beds well. Beds were available when patients needed one, including after patients had been on a period of leave.

The hospital had a clear admissions criterion, which excluded patients they were not able to care for. The hospital manager kept a referrals tracker. This showed that some referrals had been declined following assessment, due to complex care needs the hospital could not provide.

Staff worked with relevant external agencies to ensure patients were discharged at the earliest opportunity.

The hospital was not purpose built, and the layout was not ideal. There were some quiet areas for patients, along with some meeting rooms. At the time of this assessment occupancy was low. We were concerned that as the patient numbers increased, the environment and space might prove more challenging. The communal lounges and dining areas on the wards were small.

The service met the needs of their patients, which included those with protective characteristics, without judgement. Differences were embraced and respected. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw staff tried to engage patients in their care and treatment through one-to-one conversations, and in MDT meetings. Patients were encouraged to contribute to their care plans and to express their views and preferences. Staff supported patients to make decisions on a day-to-day basis around their plans for the day, to try to facilitate individual wishes. Where patients required escorted trips out, staff tried to arrange these in advance.

Patients were encouraged to raise any thoughts and feelings around care and treatment, as well as the environment through regular community meetings, patients feedback forms, through the advocacy service, or through a complaints process.

Staff supported patients with activities outside of the hospital. Visits from family and friends were encouraged. The hospital had an arrangement with a local leisure centre, so patients could use facilities at no individual cost. Staff encouraged patients to use local, community facilities, such as the local library and places of worship.

Staff actively supported patients to maintain contact with their families and carers. This was particularly important for many patients who were not in their local area. Patients and carers we spoke with confirmed visits had been facilitated where possible, with flexible visiting times, enabling visitors who had a significant journey to make the most of their time with their loved ones. Where face to face visits were not possible, video calls were supported.

Staff respected and supported patients to access their chosen places of worship in the local community. The hospital had a multi faith room for patients who were unable to leave the hospital, to use for quiet time, reflection and prayers.

Senior staff notified external bodies of incidents as expected, in a timely way. This included notifications to CQC and referrals to the Local Authority.

Governance systems maintained the confidentiality of patient records. Most records were held electronically. Patient information displayed in the nursing office could be screened off so patients looking in could not see information about co-patients.

Patients were aware they could obtain various information about diagnosis, treatments and local support services throughout their stay. Each ward held relevant and up to date information on how patients could make a complaint and seek support from advocacy. Information could be tailored to individual need, for example, in easy read format, or in languages other than English.

Where patients had consented, staff ensured relevant carers and family members were regularly updated about ongoing progress.

The service made it easy for patients to give feedback, share ideas, or raise concerns about their care and treatment. Staff facilitated weekly community meetings which patients were encouraged to attend on each ward. The meetings had a set agenda and sought feedback from patients on several areas. This included, but was not limited to what has gone well, what activities patients had enjoyed, ideas for further activities and feedback about the food.

Feedback from patients was acknowledged and acted upon by the service. For example, we saw some patients had complained that the hot water on the wards went cold which meant they could not always have a hot drink when they wanted one. The manager, as an interim measure, arranged staff to replenish the hot water 2 hourly. Appropriate flasks had been identified and were in the process of being ordered, which would keep the water hotter for a longer period. The chef regularly spoke with patients to gather feedback about the food and menus and welcomed requests.

Patients participated in their MDT meetings. This was an opportunity for patients to discuss their ongoing care and treatment and ask any questions.

Patients we spoke with knew how to make a complaint. Staff knew how to escalate complaints to the manager. The service had a complaints policy in place which set out how complaints were managed. The manager logged formal and informal complaints. Between 1 April and 5 August 2025, the provider had received five complaints, one formal and four informal. We saw that each of these had been addressed in line with policy. Senior staff had taken a variety of actions to resolve, including conducting investigations as necessary, meeting with staff and patients, and facilitated additional supervision with staff. The formal complaint had been partially upheld, and there was identified learning from this. No complaints had been escalated to the Ombudsman. There were no themes around complaints the service had received.

During the same timeframe, 24 compliments had been received about the service. These had been feedback from patients during community meetings, as well as feedback given from visitors. Examples of compliments received included staff professionalism and kindness, food quality, and patient care across both King and Castle wards.

The service did not accept patients they were unable to accommodate. All referrals were reviewed by the MDT with a unanimous decision being made. The MDT undertook relevant assessments, such as OT assessments for individual patients on an individual needs basis, and provided any identified aids identified, for example a shower chair or mobility aid.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency. At time of assessment, they had a resident doctor onsite.

Staff planned for patients’ discharge, including good liaison with care managers / care co-ordinators. Staff worked with partners to ensure patients had access to post-discharge care, for example through their local community mental health teams or crisis services.

Any delays in discharge had not been the result of inaction by the hospital. At time of assessment the hospital had 3 delayed discharges. We saw that the manager had been actively pursuing discharge with the relevant care teams. There had been difficulties with finding alternative placements which could meet the individual patient needs and who had beds available. We were informed that one patient was discharged shortly after our onsite visit. The 2 further discharges of patients were being progressed, with the expectation for these patients to be discharged over the coming weeks.

All staff undertook training in equality and diversity as part of their induction. At time of assessment, 98% of staff had undertaken and were up to date with this training. The provider had an up-to-date Diversity, Dignity and Inclusion Policy in place, which was accessible to staff. The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

Patients had good access to independent advocacy in line with requirements. Posters throughout the hospital encouraged self-referral. Staff made referrals on behalf of patients when they needed support to understand their rights. Advocates also held regular drop-in sessions, ensuring advocacy was accessible and visible to all.

The service demonstrated inclusive practice in responding to individual characteristics and circumstances. A transgender patient was supported to reside on their ward of their choice and attended LGBTQ+ community groups. Staff respected preferred pronouns which was reflective in care documentation.

Cultural, religious and spiritual needs of patients were considered by staff. We saw wash pots in bathrooms for religious washing, access to a multifaith room, as well as a variety of culturally appropriate food being offered.

Adjustments were made for pregnant staff, including alternative duties and individualised risk assessments, ensuring their wellbeing was protected without disadvantage.

Staff recognised that the nature of the ward meant that patients generally, were not considered to be long stay patients. Commissioners could recall patients as a bed became available in their local area. However, staff supported patients to make decisions about their care and treatment and their future care, while they were at the hospital. Staff regularly communicated with patients’ home care teams to ensure adequate planning of future needs, particularly patients with complex needs.

Staff created personalised care plans to account for the patient’s needs, wishes and feelings. Patients were encouraged to share their views and contribute to decisions made about their care and treatment from the point of admission.

Patients and carers we spoke with spoke positively about staff actions regarding future planning and discharge arrangements.