Archived: ST ELIZABETH

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• 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 remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service continued to be in breach of legal regulation in relation to people’s safe care and treatment and safeguarding.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

We were not assured staff were confident in identifying and reporting relevant safeguarding concerns. During our inspection we identified multiple safeguarding concerns which had not been identified by the staff or managers, and had not been reported both internally or externally. This meant no appropriate, timely action had been undertaken in response to the concerns.

For example, we reviewed multiple body maps completed for people living at the service. These documents were undated, but we were told by leaders these had been completed the previous week. These records identified bruising, skin tears, moisture damage to skin and other wounds and injuries which had not been reported or investigated. For one person, their body map identified, "Bruising to private parts and pain inside." This had not been escalated by the staff to the manager at the time of completing the body map, the manager stated they had not reviewed the body maps yet, and so no report or investigation had been commenced.

The provider failed to ensure people consistently received care that was adequate to their needs. For example, we observed multiple people without access to drinks, people who did not have food and were telling us they were hungry. Records we reviewed related to people’s diet and nutrition showed missed meals. Hydration records did not indicate people were offered sufficient levels of fluids to meet their assessed targets. We observed one person looking through their belongings for food.

We saw risks of avoidable harm were not managed safely, meaning people were left at significant risk amounting to neglect. This included risk of falls, pressure injuries and skin deterioration, dehydration, malnutrition and weight loss. We saw people had dirt ingrained in their nails and had malodourous breath and visibly dirty teeth, with records showing their oral care and personal care were not being carried out regularly.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people's health, safety and wellbeing were not effectively assessed, and care plans did not identify measures required to manage risks. Care plans and risk assessments had not been updated and did not reflect the current needs of people living at the service.

Concerns identified on our previous inspection had not been addressed. For example, measures in place to manage risk of falls were not adequate. One person had a motion sensor alarm that sounded when they moved. Their care plan stated staff were to check on them should the alarm stop sounding, as this meant they may have fallen. This person had fallen in February 2026. There was a 4 hour gap between their last welfare check and when they were found. They had hit their head, sustained skin tears and required hospital admission. This meant the plan in place to mitigate the risks to the person was not effective.

Following the person’s discharge back to the service, there falls risk management plan had not been changed, and they had experienced another fall since. This demonstrated the service had not learnt from incidents and implemented appropriate measures to keep people safe.

Other people had motion sensor alarms which required a response if they sounded. These alarms were not labelled appropriately in the living room, where the speakers were plugged in, so staff could not identify which person's alarm was which. Staff were unclear whose alarm was which. This also included the manager, and the deputy manager who were unable to tell us who or how many people had motion sensor alarms in their rooms.

People were not being re-positioned in line with their skin integrity risks and plans. Records showed gaps of 8+ hours between re-positioning for people, supported in bed, who required staff support and repositioning at least every 4 hours. We were not assured records in place were accurate, as these did not reflect the observations we made of people's position in bed.

One person, who had wounds to their buttocks, did not have a plan in place to ensure they were supported to move regularly. They had a care plan in place which stated they were advised to have bed rest for an hour in the day but declined. No other management plans were considered in reducing this risk. Their topical medicines administration record did not reflect that they were receiving prescribed sprays and creams to manage this wound.

On our previous assessment, we identified 1 person had been diagnosed with epilepsy. Their care plan did not include any information about how their seizures presented or how to manage any seizures. The plan did not include how they were monitored, or how and when staff should seek emergency or non-emergency support. This had not been addressed since the last assessment, and the person remained at significant risk should they experience a seizure.

We were not assured the service had adequate measures in place to monitor people's physical health and escalate changes or concerns. We were notified of an incident related to 1 person who had fallen and sustained an injury. On our review of records at the service, staff recorded the person had a urinary tract infection and was on antibiotics. They had worsening symptoms, including delirium and hallucinations which were not escalated by staff. They then fell and hit their head. Staff did not undertake post-falls monitoring checks in line with requirements. They subsequently noted the person was sleepy for more than 11 hours after the fall before calling for medical assistance.

Another person's physical presentation and needs had significantly changed in the six weeks since their admission to the service. When they moved into the service, they were independently mobile with support. On the day of the assessment visit they were supported in bed, unable to communicate, and unrousable with writhing movements. This deterioration had not been escalated to health professionals.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

Staffing levels had increased in the daytime since our last inspection. However, staff skill and knowledge was lacking. We were not assured staff understood the risks to people, how to identify and report safeguarding concerns, signs of physical health deterioration and safe moving and handling. While staff appeared kind and well-meaning, they did not have clear roles. There was no structure to the staff allocation to ensure tasks were undertaken appropriately and people's needs were met.

We were not assured clear management and oversight was in place to enable staff to have a good understanding of the requirement of them. There was no clear role modelling and follow-up of delegated tasks or responsibilities. The manager undertook walk-arounds; however, these appeared focussed on facilities and equipment and did not identify or address the concerns related to people's personal care needs not being met that we identified on this assessment.

There was no clear structure in place to ensure communication and handover between staff shifts. There were agency staff in use to ensure sufficient numbers of staff, however records in place were not accurate. This meant we were not assured staff were provided with relevant, up to date information in order to meet people's needs.

We had previously raised concerns related to safe moving and handling of people. Training had been implemented for some staff. However, the course content did not include hoist transfers or use of equipment, which had been identified as a concern previously. An allegation of inappropriate moving and handling had not been managed appropriately. The staff member was re-deployed on duty without updated training having taken place. When this was raised with the current interim manager, they were taken off duty until this training had been completed.

We did not review recruitment records or processes as part of this inspection.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.