Elizabeth Court

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

This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation 12 in relation to people’s safe care and treatment.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to drive improvements, when learning had been they could not demonstrate how this has been shared amongst the staff team.

The provider did not make sure people were assessed and care plans devised when they moved into the service. We identified one person who had been living at the service for 17 days, who only had 2 risk assessments and care plans in place. Therefore, staff did not have the information required to support people safely. Whilst referrals were made to other health professionals this was not always in a timely manner. We identified that where some people were losing significant amounts of weight, they had not been referred to a dietician. Handover records did not contain relevant and up to date information about a person and some records contained inaccurate information about people’s dietary needs. People did not always have access to dental treatment if required.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. For some people the relevant safeguards were not in place, this included the Mental Capacity Act 2005 (MCA) not being followed. MCA is in place to promote and safeguard decisions within a legal framework.Staff we spoke with where familiar with the adult safeguarding policy and procedures, however some staff we spoke with did not understand the Mental Capacity Act.

The provider did not always work well with people to understand and manage risks. Some people did not have risk assessments in place for an identified concern. This placed people at risk of avoidable harm as not all staff had the information required to support people safely. Where risk assessments were in place, they often lacked sufficient detail and clear guidance for staff to ensure risks were appropriately mitigated. For example, risk assessments for people with diabetes did not specify the blood glucose levels that would require medical intervention, nor did they outline the signs and symptoms of hypoglycaemia or hyperglycaemia. In one instance, a person’s risk assessment incorrectly referred to another individual. Additionally, some people were missing essential risk assessments altogether, such as those related to mobility.

The provider did not always detect and control potential risks in the care environment. People, relatives and staff raised concerns regarding the environment. Comments included, “The furniture is old and dated and damaged, [person] chair in their room hasn’t had a cushion seat for months and most chairs are broken, floor is always very sticky,’ ; ‘Several occasions I have had to request staff to clean up fluid spillages on the floor, particularly in the bathroom to prevent falls” and ”We need cleaner environment, better quality food and furniture”. The provider had not taken any action to address the concerns regarding the environment. We identified radiator covers were broken, chairs missing cushions and wheelchairs with broken straps and missing foot plates. Although an action plan was in place, no actions relating to the care environment had been completed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. A staff member told us due to the needs of people, and the staffing levels, this meant care and support was tasked based, as there wasn’t enough time to sit with people and provide care. We observed occasions where people were left unsupervised in communal areas, such as lounges or dining rooms, without staff present to provide support.

At the time of our assessment, only 3 staff members had completed face-to-face moving and handling training. As a result, the remaining staff had not yet received this training, which posed a risk of unsafe moving and handling practices. The manager informed us that staff had been scheduled to attend the training.

The provider did not assess or manage the risk of infection. We identified used continence aids being disposed of incorrectly, being placed in bins not suitable for this type of waste. We identified that some people’s bedding was unclean. Areas of the home presented an infection risk due to damaged furniture making it difficult to clean effectively.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some people were prescribed medicines to be taken ‘when required’ or with a choice of dose, but the protocols to support the safe administration of these were either not in place or were not personalised. Where there was a variable dose of medicine, there was no guidance for staff when deciding the most appropriate dose to administer. This meant people may not get their medicines consistently and at the time they were needed. We identified topical creams were not always stored safely, we found them being stored in some people’s bedrooms. One person was prescribed 2 topical creams, however these could not be found. Some people needed medicines to be hidden in food or drinks, known as covert administration. There was no information available, from a pharmacist, for staff to follow as to the safest way to disguise each individual medicine. Where guidance had been sought it was not being followed, for example one person’s medication was to be administered with water however their care plan said it was to be administered with a cup of tea.