- Care home
Elizabeth Court
We served a warning notice on Key Healthcare (St Helens) Limited on 25 July 2025 for failing to meet the regulations relating to safe care and treatment and good governance at Elizabeth Court.
Assessment report published 13 August 2025
Contents
Ratings
Our view of the service
Date of assessment 7 July 2025 to 18 July 2025. This assessment was in response to concerns raised with the Care Quality Commission. Elizabeth Court is a residential care home providing personal and nursing care to up to 44 people. The service provides support to older people. At the time of our inspection there were 42 people using the service. Some of whom live with dementia.
Elizabeth Court accommodates people across two separate floors, each of which has separate adapted facilities. During the assessment we looked at all 5 Key questions.
Our inspection identified that care plans and risk assessments were not consistently accurate or sufficiently detailed to ensure people’s safety. Additionally, care plans did not always reflect individuals’ preferences or choices.
We found that people’s nutritional needs were not always correctly recorded, which increased the risk of choking or aspiration.
The provider was not fully adhering to the principles of the Mental Capacity Act 2005. There was insufficient evidence to demonstrate that all reasonable steps had been taken to support individuals in making their own decisions. Furthermore, where decisions were made on behalf of individuals, appropriate documentation to show these were made in their best interests was not always in place.
People were not consistently repositioned in accordance with their assessed needs, placing them at risk of skin breakdown.
Personal Emergency Evacuation Plans (PEEPs) were found to be inaccurate, potentially compromising individuals’ safety in the event of an emergency evacuation.
Staff did not always have the necessary training to support people safely and effectively.
Medicines were not always managed safely. Protocols for administering ‘as required’ (PRN) medicines lacked sufficient detail to guide staff on appropriate dosage and timing. In cases where medicines were administered covertly (e.g., hidden in food or drink), there was no evidence that professional advice had been sought to ensure safe and effective administration. This is particularly important, as some medicines can lose their effectiveness or become harmful when mixed with certain foods or drinks. These issues placed people at risk of not receiving their medication safely or appropriately.
Governance and quality systems were not effective to assess and monitor the care and treatment provided within Elizabeth Court.
The provider was previously in breach of legal regulations in relation to safe care and treatment and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations. Additionally, we identified a new breach of Regulation 9, relating to person-centred care.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of care they provide.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
People's experience of this service
Some people could not directly tell us about their experience of care. To understand the quality of support they received, we used a structured observation tool. This revealed a lack of meaningful interaction between staff and people living at the service. Throughout the observation period, none of the staff were seen speaking with or engaging people in conversation or activity. People were left without stimulation or opportunities for social interaction, which is not consistent with person-centred care. This approach does not support people’s emotional or cognitive wellbeing.
People and their relatives told us they had not been involved in planning their care and had not seen a copy of their care plan. They also expressed concerns about a lack of meaningful activities to support engagement and promote wellbeing.
Despite these concerns, people using the service and their relatives spoke very positively about the staff team. Staff were consistently described as kind, caring and considerate.
Whilst not everyone was familiar with the manager, individuals and their relatives said they felt confident in how to raise a concern or make a complaint if needed.
The manager was reported to have an open-door policy, and relatives told us they felt welcome to visit the service at any time.