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 remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, some incidents were missing from analysis records.

The registered manager maintained a record of accidents and incidents and this was reviewed. A relative told us that when their loved one had been involved in an incident, action was taken to reduce the risk of a reoccurrence. People’s care plans reflected when there had been changes to their needs, for example following a fall to reduce the risk of a reoccurrence.

There were also checks on the quality and safety of care. There was analysis of trends such as with safeguarding incidents, complaints, compliments. These were positive; however, the safeguarding analysis did not always reflect all of the incidents logged on the list of safeguarding referrals kept by the registered manager. This meant there was a risk the analysis may not effectively identify trends if some incidents are missing.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However, improvements were needed to handover processes to ensure vital information was always passed over to staff and management as needed.

One person missed an urgent medical appointment. The records showed, and we were told by a professional, this appointment had been communicated to staff, but systems in place had failed to effectively ensure this was handed over. This meant the person experienced a delay in their condition being reviewed or treated. Once this was raised with the registered manager they booked another appointment.

Systems introduced to monitor people’s care needs, such as bowel movements and fluid intake, had already been established and these were embedded. The registered manager had continued to use these to ensure people remained healthy.

We received feedback from partners. One visiting professional told us, “It’s a lot better. You can see them trying to change things. It’s a lot more relaxed. I think they do better now there are less residents. The residents seem happy. We’ve noticed a massive difference.”

People were protected from abuse. Staff understood their safeguarding responsibilities and concerns were reported to the local safeguarding authority as needed.

One person did raise concerns with us during the inspection, and we made a safeguarding referral about this. We shared the concerns with the registered manager, and they investigated the concerns and took action.

One person told us, “I feel safe here.” Relatives felt their loved ones were safe and staff had a nice approach with people. One relative said, “The staff are so brilliant with my relative, so kind and caring. I don’t think they could do anything better; they are not rude or horrible.” Another relative commented, “My relative is fine, feels safe and I am assured my relative is safe there.”

Staff knew of the different types of abuse, how to recognise this and what action to take. One staff member told us, “Physical, verbal, psychological and neglect are types of abuse. If I noticed that a resident had become withdrawn, had a lack of confidence, a change in facial expressions when in the presence of another person or had physical symptoms such as bruising, then I would suspect that abuse might be occurring. I would report this to my manager, but I could go direct to the safeguarding team, and I would also share it with CQC if I thought that it wasn’t being dealt with appropriately. I don’t have any concerns about abuse occurring in the home now.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. There were assessments of people’s mental capacity, and the registered manager had applied for Deprivation of Liberty Safeguards (DoLS) where necessary. There was a tracker in place to ensure DoLS remained valid, and this was reflected in people’s care plans.

The provider did not always work well with people to understand and manage risks. Despite this, staff provided supportive care and knew people well.

People’s care plans were reviewed regularly. They continued from the previous inspection to have more detail and guidance for staff. However, we found 1 person’s care plan for a health condition detailed they needed this routinely monitoring, but this had changed, and it no longer needed monitoring, which was not reflected in their plan. The same person’s care plan referred to the person being cared for in bed. The care plan had not been updated, as they were no longer cared for in bed. These did not have any impact on the person. Staff confirmed the person was not cared for in bed. There was also conflicting information about the person’s bowel movements in their plan. Records should be accurate as it increases the risk of people being supported inappropriately, particularly when agency staff are in use as they often do not know people as well as permanent staff. The provider told us the registered manager updated the person's care plans following our feedback. Another person’s plan had a detailed plan in place for their health condition, including responsibilities of other health professionals, which staff were aware of.

A staff member told us, “We are updated about changes in people’s needs or care plans normally by email, so we are aware before we start supporting them.” Therefore, it was important care plans were up to date for staff to refer to these. Despite this, staff knew people well and were able to tell us about people’s needs. They gave us examples of risk to specific people, such as falls or times when someone may become distressed and how staff supported people in those areas.

The provider did not always control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

Relatives continued to feel the environment needed improving. One relative said, “It needs a good tidy up, a lick of paint, it looks very tired and old. The outside is poor. It is very poor.” Another relative said, “[The home is] very tired looking, it needs updating.”

Hot water temperatures were being checked; however, these checks showed the water temperature was at an unsafe level in multiple people’s bedrooms. This had been highlighted by the registered manager to the provider and quotes had been sought to fix this issue. However, this had been ongoing for a number of months and no risk mitigation was in place in the meantime until it could be resolved. The Health and Safety Executive (HSE) has guidance in place regarding hot water temperatures in care homes due to the risk it can pose to people. The provider had left people at risk. Following our feedback, work to resolve this was brought forward to protect people.

At the last inspection, we found some wardrobes which were not attached to the wall in order to reduce the risk of toppling over. At this inspection we found those of concern at the last visit were now anchored to the wall, but another wardrobe was now not attached. The registered manager thought this could be due some decorating taking place. We requested they resolved this. Some furniture in bedrooms was in poor condition from wear and tear and 1 set of drawers had a split which could pose a risk to the person.

A staff member said, “The environment has improved, it’s a nicer place to work in and for the residents to live in.” Another staff member told us, “The environment has improved a lot too and residents bedrooms are much nicer.” Whereas another staff member told us the worst thing about the service was the ‘décor’.

While there were things which still needed improving, there had been a number of improvements to the environment. The home was more welcoming upon arrival and there was more decoration and posters to brighten the home. Signage around the home helped people to orient where they were. Unpainted or unvarnished surfaces had now been painted to protect them and assist in them being kept hygienically clean, such as radiator covers and woodwork in some en suite bathrooms.

There had been a change of use in some rooms to make them more user-friendly. A more restaurant-like dining room had been created. One relative said, “They have had the painters in freshening it up, they are on to that. They have changed a room into a coffee room. Big main room is now the lounge. The change is brilliant.”

Posters had been created and displayed on people’s individual front doors to provide information about that person. One relative said, “I think there have been good improvements, with the posters on the doors.” This gave staff more opportunity to get to know people and support agency staff, who may not know people as well, a topic of conversation to start with.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

One relative said, “Yes staff seem well-trained, they seem to have a lot of courses.” A staff member told us, “I have been completing my online refresher training, and I think this is ok. Management do observe our work practices and will pull us up if we are not doing something right, and they will show us the right way, and we may have to do our training again.” Another staff member said, “I had an induction including 3 days of shadowing my colleagues. I was given a mixture of face to face and online training to complete. The training was good, and I felt I learnt from it despite having worked in care before.”

There were enough staff to support people. One person told us, “If you want anything they're [staff] there.” Staff told us they felt there were enough staff. One staff member said, “Staffing levels are ok, we have enough staff but sometime the residents can have more needs than other days and this means we have to adapt, and it can be busier, but we have enough staff to cope.”

We observed people did not have to wait long for support. However, managers and staff should be mindful of the deployment of staff during the lunch time experience, so people were not left watching others eat an entire main meal before they were served their meal.

The registered manager regularly reviewed people’s dependencies to check the staffing levels were appropriate. Staffing had recently reduced, but as a person’s needs increased, this was increased to meet these changes. We were told by the registered manager the number of agency staff being used had reduced in general. Although agency staff were still being used to cover short notice absences or changes to rotas.

The provider remains responsible for assuring themselves agency staff have the skills and training to be able to support those who lived in the service. Checks had been made on whether agency staff were suitable to work in the service. One agency staff member had completed all of their training on just 1 day, so we asked the registered manager how they assured themselves this was effective training. There was not a process in place, but they decided to put in place a more thorough agency induction in response to this.

Permanent staff were recruited safely. Checks were made on the staff to make sure they were safe to support people who used the service. Checks were made on staff identity, criminal record checks and their previous employment record.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

A relative told us, “I can’t fault it [the cleanliness], there’s no smells. My relative has a cleaner every day, my relative’s bathroom is spotless.”

The home remained clean and free from persistent odours. Previously surfaces which could not be kept hygienically clean had now been painted so they could be more easily wiped. There remained some issues with flooring in some bathrooms, but work was ongoing get this addressed.

A professional who regularly visited the service said there were no smells in the service, the toilets were clean, and people’s beds made. Our observations confirmed this to be the case.

There was a staff member designated as the infection control (IPC) lead who carried out documented checks on the environment and was involved in the cleaning of the home. They checked things such as people’s mattresses and shower heads to ensure they remained safe to use. The domestic staff team recorded the cleaning duties they had undertaken so there was an audit trail.

Improvements were needed to the management of medicines overall, although there had been many improvements, so far. All stock levels checked matched records, so we could be confident staff were accurately recording what they were administering to people. Medicines were being stored safely and this was being checked, such as the temperature of the fridge, to ensure it remained in a safe range. Eye drops had opening dates on to ensure they remained safe to use, and all seen were in date.

Staff were identifying when stock levels were running low and had contacted the pharmacy to get replacements for these; however, people had still run out of medicines and the home did not chase the pharmacy again for these to try and reduce the risk of people running out of their medicine.

Some records needed improving. One person’s protocol for a ‘when required’ medicines stated it was a variable dose, but this was not the case. There was no impact as the medicine had been administered correctly according to records. Another person was given a ‘when required’ medicine which was not in line with their ‘when required’ protocol and the incorrect time was recorded. The medicine was administered at approximately 3pm, however, this was recorded as being given at 2:30pm. The medicine should not have been given until 3:40pm to allow a 4-hour gap between doses in line with the protocol. No harm was caused to the person; however, guidance should be followed, and administration should be accurately recorded. The registered manager told us they would review the protocol in response to our feedback. Another person was given ear drops for a prolonged period of time which was not in line with the manufacturer’s instructions, and this had not been identified or checked with a relevant health professional. Following our feedback, the registered manager sought further advice about whether this was safe to continue using, or not. There was a lack of consistency in the highlighting of Medications Administration Records (MARs); some ‘when required’ medicines were highlighted green, others were not. However, we also observed regular dose medicine also being highlighted. This increased the risk of confusion for staff.