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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

All wards were safe, clean well equipped, well furnished, maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and worked with patients to reduce known risks. Staff contacted external agencies, for example the Local Authority to report safeguarding incidents that had occurred and to offer assurances of relevant actions taken by staff.

The service used systems and processes to safely prescribe, administer, record and store medicines. Staff worked with a pharmacy who undertook regular visits to the hospital, routinely conducted audits, and offered training for staff.

The service managed patient safety incidents well, investigated these and learnt lessons from them. Managers ensured learning was shared with staff across the hospital to minimse the risk of a future occurrence.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with knew what incidents needed to be reported and how to do this. We sampled a range of incident forms staff had completed. We found staff had reported all incidents they should have reported. Descriptions within the incident forms were thorough, and it was clear what actions staff took at the time of, and following the incident.

The managers reviewed all incidents in a timely way to ensure all relevant actions had been taken, including any external reporting expectations. The hospital manager ensured relevant investigations were completed, in line with provider policy.

Ward managers disseminated any immediate lessons learnt to staff. These were discussed during regular shift handover meetings. Lessons learnt also featured in hospital wide meetings, to include staff meetings, daily MDT huddle meetings and clinical governance meetings. We saw evidence of learning following incidents. For example, after one incident, it was apparent some staff required additional training in how to manage a barricade situation. The manager organised ad hoc sessions for staff, to prevent a similar incident occurring in the future.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong.

Staff told us there was support available to them following incidents. Senior staff made themselves available. The psychologist facilitated regular reflective practice sessions. If staff needed additional support, such as counselling, this could be arranged through the manager.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could be met safely before admission was agreed. The hospital had a clear exclusion criterion to ensure suitability. Referrals came through via a standard referral form. This was comprehensive and included past and present mental health history, physical health history, past and present risks, as well as any medicines prescribed. Referrals were discussed as an MDT. Further information was requested as and when necessary. The manager confirmed there was no pressure to admit all patients referred to the service. Emphasis was placed upon if the hospital could safely meet the needs of the patients. This was demonstrated in a referral log seen, where some referrals had been declined.

We saw staff regularly maintained contact with patients’ local community teams, to provide regular updates. Care co-ordinators were routinely invited to attend MDT review meetings, which could be attended virtually. Discharge planning involved all relevant teams. We saw staff had communicated with a variety of professionals leading up to the planned discharges of patients.

Some patients at Elizabeth house were “out of area”. This meant there was no available bed in their local area. Staff acknowledged that patients could be recalled back to their local hospital if a suitable bed became available, which could happen at short notice. However, we observed discharge was discussed, and steps taken, where possible to promote a safe discharge with appropriate follow up / aftercare arrangements in place.

Staff had received training in the safeguarding of adults and children which was updated regularly. Compliance was between over 97% at time of assessment. Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff identified safeguarding concerns and escalated with other relevant agencies, such as the Local Authority.

Between March and August 2025, the service had recorded 16 safeguarding concerns. There were no apparent themes. Four of the 16 related to concerns outside of the service; 3 related to patient to patient assaults; 2 related to substance misuse; 3 related to deliberate self-harm.; 1 was around a delayed discharge; 1 was a patient who absconded; 1 was medicines related and 1 was an unexplained injury. Of these, the Local Authority reviewed and were happy with actions the service had put in place, requiring no further investigations. CQC had been notified as expected.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff provided a safe space for children when visiting the service and were flexible in facilitating visits to promote regular contact where possible.

Mental Capacity Act

Training in the Mental Capacity Act was mandatory. At time of assessment, 100% of staff had completed and were up to date with this.

Staff we spoke with had a good understanding of the Mental Capacity Act. Staff assumed patients had capacity to make decisions around their care and treatment. Staff took practical steps to enable patients to make their own decisions. Relevant capacity assessments were undertaken by the MDT when it was uncertain if a patient had impaired capacity to make a specific decision. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Staff made DoLS applications when required and monitored the progress of applications to supervisory bodies. There had not been any DoLs applications made the last 12 months.

Staff knew where to get advice from regarding the Mental Capacity Act, including DoLs. The Mental Health Act administrator was available, as was the hospital manager if advice was needed.

The provider had a policy on the Mental Capacity Act, which including DoLS. Staff were aware of the policy and had access to it. The Mental Health administrator retained oversight of activities related to capacity.

We reviewed 10 patients care records during this assessment. We saw most patients had seen, been offered, or had signed their care plans. All patients had a risk assessment which staff had updated regularly, including after any risk incidents. Patients were involved in discussions during regular MDT meetings around care and treatment, including management of risks.

Staff communicated with patients so that they understood their care and treatment. We were aware that some patients had needed written information in a language other than English, which staff had provided. Easy read material was available to patients who benefitted from this.

The service used physical intervention / restraint as a last resort. Between March and the end of May 2025, staff reported using physical interventions on 37 occasions. Most interventions were low level. There had been no use of prone (chest down) restraint. It was evident within documentation reviewed that staff used verbal de-escalation and / or distraction techniques as the first intervention.

The service kept a restrictive practice log which senior staff updated regularly. This was on the clinical governance meeting agenda, enabling MDT discussion. Restrictions upon patients had been considered, risk assessed and discussed openly with patients. We saw staff held discussions about restrictions on the wards during community meetings. Restrictions placed upon patients had been risk assessed, care planned and regularly reviewed. The service attempted to keep restrictions to a minimum, whilst maintaining the safety of patients. For example, many patients enjoyed listening to music with headphones. Patients were advised to use wireless headphones in cases where cords would be a risk. Some previous restrictions had been removed. Examples of these included set visiting times and set times for patients to access outside space.

Perspex screens were covering most of the windows within the service, inhibiting patient’s access to fresh air. This issue was raised by CQC during a previous inspection in December 2023. This concern had also been raised by some patients who had used the service. The service confirmed quotes had recently been approved for the replacement of some windows. There was a plan in place for all windows to be replaced over a 6 – 9-month period.

The fence of Castle ward courtyard appeared relatively easy to climb, with a significant drop the other side. We were informed by a staff member that a patient had previously attempted to climb this fence but had been prevented in doing so by staff. The service was aware of this risk, and mitigated this by ensuring staff presence in the courtyard,

Staff undertook regular risk assessments of the care environment to maximise patient safety. The hospital was not purpose built and had various rooms off long corridors. Staff could not easily observe patients in all parts of the wards. However, curved mirrors had been fitted throughout the wards to aid visibility in areas the service had recognised were blind spots.

The manager ensured the ligature risk assessment was reviewed and updated regularly. All identified ligature risks had clear and relevant mitigations in place. An example of this included certain areas of the wards to be used by patients under staff supervision. Staff were aware of the ligature risk assessment and knew how to access this. Staff we spoke with knew where ligature cutters were located, in the event these were needed.

Fire and Health and safety records were carried out according to the provider’s schedule, we observed no gaps in these records. Fire drills were carried out regularly, as were environmental audits.

Staff had easy access to alarms and patients had access to nurse call systems, so could summon help if needed. The ward complied with guidance on eliminating mixed-sex accommodation.

Maintenance tasks were logged by staff in the maintenance book. Recorded tasks were reviewed by the maintenance team daily. Tasks were generally signed off as completed soon after having been recorded. However, there was not a consistent record of specific actions taken by staff to remedy identified maintenance tasks.

On Castle and King wards we identified patient food items in the fridges that were opened and not labelled. Fridges needed to be defrosted. We observed an out of date, opened packet of cooked meat. This was raised with the service, who tool immediate action to address.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency medicines that staff checked regularly.

The service worked on a staff to patient ratio of 3:1. The managers were able to approve additional staff to facilitate patients’ needs, for example to support enhanced observations. The wards always had a registered nurse in charge, complimented by support workers and /or patient safety officers. Staff spent 1:1 time with allocated patients and recorded this in daily records. Staff told us they could respond to incidents in a timely way, with staff from other wards / within the hospital attending if the alarm was activated.

The hospital was fully staffed at the time of assessment. Each ward had a ward manager. The service employed 17 registered nurses and 34 support workers / patient safety officers. The manager explained that they planned to over recruit as and when patient numbers increased. The hospital had not used any agency nursing staff since 2024. They had a pool of bank staff but did not need to use these at time of assessment due to being fully staffed. Nursing rotas reviewed showed that all shifts had been covered as planned. There was medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. Compliance in all areas was over 95%. Mandatory training included but was not limited to basic life support; Infection prevention and control; breakaway and restraint. Staff had received training appropriate for the patient group using the service. This included how to manage deliberate self-harm, epilepsy and diabetes.

The service had a policy around infection prevention and control (IPC). The policy referred to ongoing training of staff and continuous monitoring of IPC through clinical audits. Compliance with IPC training was 100%. Staff we spoke with confirmed they received refresher training alongside other mandatory training.

Ward areas were visibly clean, well maintained and appropriately furnished. Clinic rooms, bathrooms and toilets were tidy and well presented. Hand sanitising facilities were readily available. Alcohol-based hand gels were placed at strategic points, including at ward entrances, to promote hand hygiene. Hand hygiene posters were displayed to reinforce best practice among staff, visitors and patients. Staff were observed to be “bare below the elbow” and appeared to follow good infection control principles.

Cleaning schedules demonstrated that ward areas were cleaned regularly by housekeeping staff as expected. The service had 3 permanent housekeepers as well as a bank housekeeper. This enabled a 7-day service across the hospital. Staff stored chemicals safely in line with safety requirements. Trolleys containing cleaning equipment were never left unattended.

A review of cleaning records from June to August 2025 showed no significant gaps. We saw occasional missed tasks. These were attributed to staff absence or when patients had declined to have their rooms cleaned. This had not impacted upon the cleanliness of the site. Housekeeping staff told us in cases where patients had consistently refused room cleaning, this had been escalated to the ward manager to help find a suitable resolution. Managers had deep cleaning schedules in place, which covered all hospital areas. Housekeepers were described positively by patients during community meetings, and feedback indicated patient satisfaction with the standards of cleanliness.

Both clinic rooms were small but had enough space for staff to safely dispense medicines. Medical and nursing staff had access to a variety of medical examination equipment. Clinics were visibly clean. Managers ensured equipment used were calibrated regularly to optimise working, such as the blood sugar monitoring devices. The service used a pharmacy. Contact details had been placed in clinics for ease.

We reviewed the clinic wards on each ward and undertook a review of medicines management. Staff followed good practice in medicines management, in line with the provider policy. Managers ensured medicines reconciliation was completed prior to new patients arriving. Information on medicines prescribed and previously used medicines was gathered at the point of referral, in line with best practice.

Staff reviewed the effects of medicines on patients’ physical health regularly and in line with national guidance. We saw patients had corresponding care plans detailing how staff monitored patients who were prescribed certain high risk medicines. We saw staff had followed these and had recorded physical health observations at the times expected. The physical healthcare lead had implemented numerous specific care plans around individual patient conditions, such as diabetes, to guide staff.

As required medicines had not been overused or used for extended periods of time without a doctors review. No patients at the service had required rapid tranquillisation.

We did observe a minor issue on King ward, where we saw a patient cream had not been labelled by staff upon opening. This was bought to the attention of the nurse who took immediate action to rectify this.