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

Leaders had the skills, knowledge and experience to perform their roles and knew the service well.

Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff demonstrated the values of the hospital in their day-to-day work.

Staff we spoke with felt respected, supported and valued. They knew they could raise any concerns they had with senior staff. Teams held regular meetings to discuss the patient group, any risks or potential challenges.

Governance processes operated effectively. Senior staff managed risks, monitored staff performance and acted upon these where necessary. Ward staff had access to the information they needed to provide safe and effective care.

Staff collected and routinely reviewed and analysed data about outcomes and performance at ward and hospital level. Where improvements were needed, action plans were put in place with allocated staff members taking leads to ensure actions were completed.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff we spoke with explained that the overall goal was to provide good care in a safe environment, and help patients to recover, enabling discharge. Senior staff communicated the providers vision and values to all new staff entering the service, through their induction period.

The MDT delivered ad hoc internal training to staff to enhance knowledge in different areas relating to care and treatment of those with mental health difficulties. We saw that recent sessions offered had been around communication, Mental Health Tribunals and CQC regulations.

Staff held regular team meetings, during which key messages about any proposed changes to the hospital were discussed. Additionally, the hospital manager had introduced a monthly drop in ‘brew / snack and chat’ session. This was an open invitation to all staff to drop in and share any ideas or general feedback.

Leaders had the skills, knowledge and experience to effectively perform their roles within the hospital. Senior staff we spoke with had a good understanding of the services they managed and were passionate about doing the best they could.

Staff told us ward managers, and the hospital manager was visible and approachable to staff, patients and visitors.

The provider offered leadership opportunities for staff. The hospital manager was undertaking further leadership training. This had also been offered to ward managers.

Some support workers had been promoted to patient safety officers within the service. The MDT had a variety of skills and knowledge. They worked together to achieve the best outcome possible for patients.

All staff we spoke with told us they felt it was important to speak up and voice any concerns, and they would not be afraid to do so. Staff told us they would speak to senior staff and / or the hospital manager and would not be afraid of any potential retribution. Staff were aware that there was a relevant policy in place about speaking up, but were not able to confirm who the freedom to speak up champion for the hospital was, or articulate the process clearly.

The service confirmed they had one champion for the hospital, and there had been no concerns raised via this route over the last 12 months. This may indicate that this process needs to be strengthened, to increase staff awareness and make accessibility to champions easier.

Patients and carers had opportunity to give feedback about the service through different methods. They were able to speak with staff, make any formal complaints, and complete feedback through routine surveys undertaken. We reviewed the most recent patient survey results, which were predominantly positive. Out of 16 respondents, 13 said they would recommend the service to friends and family.

The service shared results of the most recent staff survey (2025), to demonstrate actions taken following feedback. However, we found the wider organisation sought feedback across staff from a number of services within the healthcare group. Therefore, we were unable to extract any themes that had arisen from staff at Elizabeth house. Consequently, we were unable to report on specific actions taken because of feedback from staff at this hospital.

All staff received training around equality, diversity and inclusion. At the time of our assessment, 98% of staff had completed this. The provider had a relevant diversity, dignity and inclusion policy in place which staff could access. This policy acknowledged that staff and people using the service have different needs and had the right to the same quality of service.

We were aware that the service provided flexible working arrangements for employees, supporting home / work balance, taking into consideration family and caring responsibilities, overall wellbeing and any health conditions. The service aimed to ensure staff had adequate rest breaks in a suitable environment.

We saw how adjustments had been made for pregnant staff, steered by relevant risk assessments. Alternative, non-patient facing duties had been facilitated to ensure the safety and wellbeing of the staff during the different stages of pregnancy.

The service had a clear framework in place with set agendas of what staff discussed at ward level and hospital wide meetings. Information relating to the safe running of the service, such as identified environmental risks, incident analysis, recruitment and staff training were discussed and reviewed regularly by the MDT and senior leadership team at regular clinical governance meetings. Meeting minutes demonstrated any actions required were recorded with a lead identified. Progress of actions were revisited at the following meeting.

Ward managers disseminated any immediate lessons learnt to staff following incidents during regular handover meetings and during supervision. Lessons learnt also featured in hospital wide meetings, to include staff meetings and clinical governance meetings. The service also produced bulletins, where lessons learnt had featured.

Staff undertook regular clinical audits to monitor quality and compliance. This included health and safety / environmental audits, such as blind spot audits and infection prevention and control. Staff also undertook a wide range of audits to monitor individual patient records, such as care plan audits, physical health audits and Mental Capacity Act audits. The audits were sufficient to provide assurance and staff acted on the results when shortfalls had been highlighted.

All staff could escalate concerns around risk to ward managers or the hospital manager. The hospital manager had oversight of the hospital risk register and added new items as and when recognised. Areas of risk we found during our assessment featured on the risk register. This included, but was not limited to, reduced access to fresh air due to windows not being able to open; risks related to outside areas and ligature risk considerations.

Ward managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients.

The service had a business continuity plan. This identified procedures staff needed to follow in the event of an emergency which may result in a service disruption. Examples of these included a fire or flood, heating failure or a flu outbreak. The plan identified staff responsible for management of the incident, recording of the incident and the recovery phase.

Staff had access to the equipment and information technology needed to do their work. The electronic notes system was embedded and staff we spoke with knew how to navigate this to find relevant documentation. Staff adhered to patient confidentiality with the storage of records.

The hospital manager, along with ward managers engaged regularly with external stakeholders regularly regarding proposed admissions, as well as patients at the hospital receiving care and treatment. Commissioners were kept updated of any significant incidents or areas of concern. The managers maintained contact with CQC, informing of incidents they were required too, or to seek advice on any matters they were unsure of.

Patients were encouraged to stay in touch with relevant healthcare professionals / teams from their local areas. Staff routinely invited relevant professionals to MDT meetings to discuss progress and discharge. Patients we spoke with knew they could speak freely to staff, ward managers and the hospital manager.

The hospital was striving to improve receiving stakeholder feedback, to enable continuous improvement. They had increased the frequency of stakeholder survey collection from quarterly to monthly. As well as having paper feedback forms available, the service had posters displayed widely across the hospital with QR codes for ease of timely feedback. A tablet had also been placed in reception so visitors could see this and choose to complete any relevant feedback at the commencement, or at the end of their visit.

Staff used quality improvement methods and knew how to apply them. This was evident in some documentation seen around hospital initiatives. At the time of our assessment, staff were proud to share an ongoing piece of work they had been undertaking with patients, around meaningful activity. Staff had initially sought feedback from 9 patients across two wards. Initial findings were that patients wanted some physical health focused activities, as well as further psychological and therapeutic activities. Examples given had included muscle relaxation, animal therapy and medicine awareness workshops. This piece of work was a joint effort from different MDT members and was ongoing.

The service had been in discussions with some local universities with a view to offer a student placement programme at the hospital. The aim was to facilitate a learning environment for student nurse placements by the end of May 2026.

The service had a sustainability strategy in place around waste management. All staff and patients were expected to adhere to appropriate recycling practices and waste segregation. We saw numerous recycling bins across the hospital. The service had been unable to secure food waste collection, so had decided to begin an in-house food waste compost initiative. The longer-term plan was to produce compost, which would be used to grow edible products, such as tomatoes, which would be distributed free to staff, patients and potentially the wider community.