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 inadequate. At this assessment the rating has changed to 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.

The service continued to be in breach of legal regulations in relation to the safety and condition of the physical environment and the ways people’s medicines were managed.

This service scored 53 (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. Lessons were not always learnt to continually identify and embed good practice. A relative told us what action had been taken after their loved one had a fall, “My relative is far more comfy [now]. I’m happy about that.” However, risk assessments and some care plans were not always reviewed and updated following incidents, so they were out of date. For example, 1 person had a fall, but their risk assessment said the same person had not experienced any falls. Despite this, staff were aware the person had fallen and knew how to support the person safely. One person fell in their bedroom and staff had recorded the sensor in the person’s rooms was ‘some time [sic] working and some time [sic] not working’ but there was no recorded action this had been investigated and addressed. Further improvement was required by the management team when tracking accidents and incidents; some incidents were missing from the monthly accident and incident folder and tracker. An embedded analysis of themes and trends was not yet in place. A weekly tracker was used for incidents, but it was explained to us this was not being consistently used, and the monthly tracker was the main tracker so if concerns were missing from this they may not be fully reviewed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored, although some improvements were needed.

One staff member said they felt communication could be improved as information was not always shared with all staff members as needed. They gave us an example from the week of our inspection when staff mentioned something to a colleague and they had not been made aware, and they felt they should have been. One professional who worked with the service said while they received appropriate referrals, they felt the provider was sometimes reactive in their approach rather than proactive.

Staff were aware of people’s health needs and how often people needed support with repositioning, if they needed this. Care plans referenced when visiting professionals were responsible for some aspects of people’s medicine administration, so it was clear what tasks staff needed to complete. Signs and symptoms of someone becoming unwell as a result of their health condition were noted in care plans. There was now consistent monitoring of people’s bowel movements and fluid intake, when this was required, to ensure people did not become unwell as a result of not opening their bowels or not having enough fluids.

People were being protected from abuse; staff were aware of their safeguarding responsibilities. One staff member said, “If I had concerns abuse was taking place. I would first make sure the person was safe and then report it to management. If I didn’t see action being taken, I would escalate it to the owner and to CQC.” Relatives told us they felt their loved ones were safe. We observed staff interactions were more person-centred.

However, there was not yet an embedded system in place to analyse trends in safeguarding concerns. This can be useful to track action taken and further improve the quality and safety of care. The new registered manager had acted on feedback from the local authority about this lack of system and had implemented a new analysis process. However, this had only been completed for one month, so this was not yet embedded. We will check the provider continues to develop and embed a process for monitoring safeguarding concerns over time.

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. The registered manager had completed appropriate assessments of people’s mental capacity and had applied for Deprivation of Liberty Safeguards (DoLS) where necessary. There was a tracker in place to ensure DoLS remained valid. One person had conditions on their DoLS and these were being complied with.

The provider reduced the risk to people, where possible. Relatives felt people were safe living in Elizabeth House. One relative said, “I do think my relative is safe, yes, it’s just how they are looking after my relative now.” Another relative said, “I don’t feel my relative is not in a safe place. Even new staff seem quite clued up with residents. My relative is safe and warm and looked after, they [staff] get in touch if there’s an issue.” Another relative said, “I do feel my relative is safe, I wouldn’t leave them there otherwise. I feel better now there has been scrutiny. I think it’s good the home has been under scrutiny.”

Staff were aware of people’s needs, such as in relation to their moving and handling needs and times when people may become distressed. For example, a staff member was able to explain to us about how a person’s needs had changed after the person had fallen, and we saw this was the case.

People had more detailed care plans in place, which guided staff about people’s needs and preferences. One staff member said care plans were ‘loads better now’ and felt they were more detailed.

We observed safe moving and handling. People were wheeled in wheelchairs with their feet on foot plates and staff reassured and encouraged people to participate during moving and handling support. However, there was an instance of a person being supported to stand up by 2 staff members to transfer to a wheelchair, but 1 staff member had not unfolded and prepared the wheelchair ready for the person. The person then stood, and the staff member had to try and unfold it with 1 hand while supporting the person with the other. A third member of staff then entered the room and assisted. Staff had not prepared to support this person safely.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Relatives felt the home environment needed improving. One relative said, “The only things I would say about the rooms is they need updating. The bathrooms are basic. The place needs updating.”

Another relative told us, “I just think it’s a shame they have the residents in the back gloomy room. Considering people are spending most of their waking time [in communal areas].” The same relative also commented about the poor condition of the outside space, “There’s nothing there but weeds. [The provider] has said it [the outside space] is work in progress and that the garden is going to be done, even though during COVID it was the same. I don’t think any of them get any fresh air, they are stuck in the back room.” Another relative said, “The outside of the building is uninviting. I’m hoping in time they will refresh the bedroom; it is dilapidated, it’s not been touched for a long time. The outside [of the building] is a mess.”

One staff member said, “The rooms could be updated. If we see something, we can mention it to the office, there is a maintenance book.” Another staff member said, “I think the environment could be better, it’s poor in places and some bathrooms are very small and make assisting people difficult.”

Some improvements had been made to the environment, such as control measures being put in place to lock cupboards and rooms which contained hazards. There was 1 observed instance of a cupboard with hazards in being left unlocked, but this was then re-locked after we fed back about this. Hot pipes had been covered to reduce the risk. A communal bath had been cleaned and sealed as needed. Window restrictors now appeared tamper proof. Work was underway to rectify defects with fire doors. Proactive checks were made on the building such as gas safe, electrical, emergency lighting and fire alarm checks and checks on lifting equipment to ensure they remained safe.

However, many more improvements were needed. The flooring was in poor condition in some communal bathrooms, there was wear and tear to doors and walls throughout the building including peeling wallpaper in some areas. There was 1 toilet frame which had missing rubber feet so it would have not afforded the designed level of grip, so this needed fixing or replacing. There were 2 unsecured wardrobes which could pose a toppling risk to people, as the fixings had broken. We asked the provider for these to be fixed, and a review take place of all furniture which could pose a toppling risk to people. Checks on the securing of necessary furniture was not included in audits, so this had not been identified.

There was no regime in place to check the temperatures of hot water from some outlets, to ensure it remained a safe temperature. This is guidance in place from the Health and Safety Executive (HSE) about maximum temperatures in care homes, as temperatures above safe levels can pose a scalding risk. We found 1 tap which was potentially too hot. This was in a bedroom that was not in use, but had someone moved into that room, it may not have been identified as there was no system in place to check this and it could have put a person at risk. Action was taken following our feedback to put checks in place. Tests on water hygiene had been carried out as needed.

The management team and provider acknowledged further work needed to be done. There were no directly employed maintenance staff to be able to work in the home on an ongoing basis, so they relied on external contractors. Attempts had been made to progress work, but the provider explained they had experienced difficulties engaging trades people to complete necessary work or the quality of work by some trades people was not always of sufficient quality. We were told there was a plan of refurbishment for bedrooms, and while planning had started, the work had not yet commenced. We will check this work goes ahead at our next inspection.

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 person commented, “I can't say staff don’t come quickly. If they don’t, I ask again." A relative said, “Staffing is far better now. They have come straight away.” A visiting professional also told us they felt staffing levels had improved, “There’s a lot more staff than there was.” We observed people did not have to wait long for support.

There was a dependency tool in place to determine staffing levels which looked at people’s level of need and calculate the number of staff needed. The rotas, and our observations, showed this was being followed.

Staff told us they received training to be confident in their role. One staff member told us, “I did 3 days shadowing and had some online training and some face to face. It gave me the knowledge I need to do my job.” Another staff member said, “I did 3 days shadowing staff as part of my induction and did some training which added to my existing knowledge.” The monitoring of staff training had improved, and staff were largely compliant with the completion of the training set for them.

A staff member confirmed they had been observed administering medicines to check their competency. They said, “I think it was checked a while ago and again more recently. If I’m not sure of anything, I will ask. I’d rather ask than just do it and it not be right.”

Staff were recruited safely. Checks were made on staff members right to work and on their suitability for the role. There was evidence of references from previous employers, employment history and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. The home appeared generally clean. However, the condition of the environment meant certain areas or items could not be kept hygienically clean.

One relative told us they felt the cleanliness was the best thing about the home. Another relative said, “My relative’s room always smells fresh, and the bathroom is clean.” Another relative commented, “It’s clean, I do a spot check, it’s good to see my relative’s bed is always made.” The same relative confirmed they observed staff wearing aprons and gloves, “Even when giving out food.” One visiting professional said, “The home is better than it was. It doesn’t smell now.”

We observed staff wearing gloves and aprons, when necessary. There were no persistent malodours in the home.

There was a nominated staff member who was the infection prevention and control (IPC) lead. They carried out audits and identified areas for improvement. The audits carried out by the IPC lead showed improvement to the overall compliance in the home.

There continued to be multiple unpainted surfaces (such as radiator covers) so they could not be kept hygienically clean, including in some en-suite bathrooms so they were becoming water stained. Flooring in some communal bathrooms was not sealed so could pose a risk.

Many improvements had been made to medicines processes after the last inspection; however further improvements were still needed.

One person said, “I take tablets every morning." We watched people being given their medicines by 1 member of staff. They followed safe practice and treated people with respect.

Records were kept of medicines prescribed for and given to people. These showed that people received their medicines at the times that they needed them. However, 1 person had been without a regular medicine for 12 days when their supply ran out. Another person’s medicines administration record showed that 2 of their medicines had been stopped. Staff were not clear why this had happened and were contacting the doctor to confirm if this was intentional or an error. One person had a medicine which should be given before having anything to eat or drink and prior to any other medicines, however it was being given at the same time as all the medicines the person was prescribed.

Medicines records identified medication allergies, though this information was not included on the medicines administration records as is best practice and in line with the home’s policy.

When people had been prescribed medicines to be given on a ‘when required’ basis, detailed person-centred protocols were in place for most people to support them to receive their medicines in a clear and consistent way. However, there were some instances of missing protocols. The outcomes of ‘when required’ medicines were assessed and recorded to ensure they were effective. When people were prescribed more than 1 medicine, on a ‘when required’ basis to treat the same condition, the care plans did not describe how staff would decide which medicine to give or whether to give both, contrary to the home’s policy.

The provider’s role in relation to people’s medicines was defined and described in relevant policies, procedures, and training. However, staff were only able to find and show us a limited number of the medicines policies and these did not describe all the procedures needed to manage medicines safely.

Medicines, including controlled drugs, were stored securely, at the correct temperature and within their expiry date. Medicines with a limited shelf life were dated appropriately. Records were kept of medicines received into the home. Medicines were disposed of safely when no longer required and suitable records made.

Governance and audit arrangements for the oversight of medicines were not effective. Audits were incomplete and issues were not being resolved.