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Inspection Summary

Overall summary & rating


Updated 4 May 2018

The inspection took place on 28 February 2018 and was unannounced. Elizabeth House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Elizabeth House is situated in Bognor Regis in West Sussex and is one of a group of homes owned by a national provider, Shaw Healthcare Limited. Elizabeth House is registered to accommodate 60 people. At the time of the inspection there were 57 people accommodated in one adapted building, over three floors, which were divided into smaller units comprising of ten single bedrooms with en-suite shower rooms, a communal dining room and lounge. These units provided accommodation for older people, some of whom were living with dementia. There were gardens for people to access and a hairdressing room.

The home had a registered manager. A registered manager is a ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run. The management team consisted of the registered manager, a deputy manager and team leaders. An operations manager also regularly visited and supported the management team.

At the previous inspection on 14 and 17 February 2017 the home received a rating of ‘Requires Improvement’ and was found to be in breach of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following the last inspection, we asked the provider to complete an action plan to inform us of what they would do and by when to improve the key questions of safe and well-led to at least good. This was because there were concerns with regards to the sufficiency and deployment of staff to flexibly meet people’s changing needs and ensure their safety. In addition, there were concerns with regards to the completion of records to confirm staff’s actions and the failure to action issues that had been identified within audits. At this inspection improvements had been made and the provider was no longer in breach of the regulations. However, we found one area of practice that needed to improve.

The management team and staff had a good understanding of the Deprivation of Liberty Safeguards (DoLS) and had worked in accordance with this. However, although staff gained people’s consent before supporting them with day-to-day tasks, there was an inconsistent approach to formally assessing people’s capacity and gaining their consent. This is an area of practice identified as being in need of improvement.

The registered manager and staff worked hard to promote a welcoming, inclusive, friendly and lively atmosphere. People told us they were happy living at the home. Without exception, people, relatives and healthcare professionals told us that staff were consistently kind, caring and compassionate and our observations confirmed this. Comments from people were positive. They included, “I like it here very much; the staff are all very kind and attentive”. Another person told us, “Yes, the staff here are very kind, they could not be nicer. I am fortunate and do not have any medication or mobility problems, but I can see the amount of care that is given to some of the other residents. It is wonderful and I know that I would be looked after properly here if ever the time came”. People were treated with respect and dignity, their privacy maintained. Independence was promoted and encouraged and people could choose how they spent their time.

The provider had a clear set of values that encompassed a person-centred approach and these values were embedded in the culture and the practices of staff. The provider and management team had good quality assurance processes and audits that monitored the practices of staff and the effectiveness of the systems and processes at the home. Action plans were implement

Inspection areas



Updated 4 May 2018

The home was consistently safe

There were sufficient numbers of skilled and experienced staff to ensure current numbers of people living at the home were safe and cared for.

Staff were aware of how to recognise signs of abuse and knew the procedures to follow if there were concerns regarding a person�s safety. The provider demonstrated a reflective approach and implemented changes when lessons had been learned from incidents.

People had access to medicines when they required them. There were safe systems in place to manage, store, administer and dispose of medicines.


Requires improvement

Updated 4 May 2018

The home was not consistently effective.

People were asked their consent before being supported. The provider was aware of the legislative requirements in relation to gaining consent for people who might lack capacity but had not consistently worked in accordance with them.

People were cared for by staff that had received training and had the skills to meet their needs. Staff worked with external healthcare professionals to ensure that people received appropriate and coordinated care.

People had access to healthcare services to maintain their health and well-being. People were happy with the food provided. They were able to choose what they had to eat and drink and had a positive dining experience.



Updated 4 May 2018

The home was consistently caring.

People were supported by kind and caring staff who knew their preferences and needs well and who could offer both practical and emotional support.

People were treated with dignity and respect. They were able to make their feelings and needs known and were able to make decisions about their care and treatment.

People�s privacy and dignity were maintained and their independence promoted.



Updated 4 May 2018

The home was consistently responsive.

People had access to a wide and varied range of activities and facilities. People were supported to engage in meaningful activities and there was a fun, lively atmosphere.

People were involved in the development of care plans. These were detailed and provided staff with personalised information about people�s care.

People and their relatives were made aware of their right to complain. The registered manager encouraged people to make comments and provide feedback to improve the service provided.



Updated 4 May 2018

The home was consistently good.

There was a positive culture that ensured that people were involved in decisions that affected their lives and support was tailored around their needs and preferences.

Good quality assurance processes ensured the delivery of care and drove improvement. The management team maintained links with other external organisations to share good practice and maintain their knowledge and skills.

People, relatives and staff were consistently complimentary about the leadership and management of the home.