ST ELIZABETH

Ratings

• Overall

  Inadequate

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Inadequate

• Responsive

  Requires improvement

• Well-led

  Inadequate

Our view of the service

We carried out this assessment between 3 and 27 March 2025. This assessment included 4 site visits to the service. St Elizabeth is a care home that can accommodate up to 17 people, some of whom were living with dementia. At the time of our assessment there were 13 people living at the service.

During our assessment we observed care and reviewed people’s risk assessments, care plans and medicines administration records. We reviewed policies, procedures, training records, incident records and other relevant documentation.

This assessment was completed to check the provider had made improvements following enforcement action taken after our last assessment in August 2024, where we found breaches of regulation in relation to person centred care, need for consent, safe care and treatment, safeguarding, governance, staffing, recruitment and failure to notify CQC. This resulted in CQC issuing warning notices and imposing conditions on the providers registration.

At this inspection we found significant shortfalls and the provider had failed to make sufficient improvements and continued to be in breach of regulations. The care being provided to people was not person-centred and people’s records failed to demonstrate care provided to people took into account their needs and preferences. The provider failed to demonstrate they sought consent or enabled people to make decisions in line with the legal framework. Processes for safe care and treatment were ineffective and placed people at risk of avoidable harm. The provider failed to ensure people were appropriately protected from avoidable risk of harm.

The provider failed to implement effective systems to assess, monitor and improve the service. We were not assured staff were always suitably trained and the provider’s oversight of training was not effective in ensuring staff received training appropriate to their role in a timely manner. The providers recruitment process had not improved and there were continued shortfalls in relevant required checks. In addition, we found a new breach in regulation in relation to dignity and respect.

The provider did not have effective governance systems in place to monitor and improve the quality of the service. Environmental risks were not monitored and managed effectively and people were placed at avoidable risk of harm through lack of risk mitigation. Care plans were not person-centred, accurate or up to date.

In instances where CQC has 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.

This service has been 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 user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

People's experience of this service

During the inspection we spoke with 6 people and 11 relatives, this included conversations with relatives both on and off site.

We received mixed feedback from people and their relatives about their experiences of the service and the care provided. Some people and relatives spoke warmly about the care staff delivering care. However, others did not and felt there were aspects of the service that needed further improvement including the environment, activities, communication, staffing and management.

During our assessment we found significant shortfalls in people’s experience of care, such as neglect of people’s personal care delivery.

People’s experience of care was not always person centred and some people’s preferences in relation to dietary requirements had not been respected. For example, foods that were recorded as dislikes were given. Some people’s preferences had not been considered in relation to personal care. For example, a person expressed the assistance of female staff to help meet their personal care needs, however, records demonstrated that at times personal care was being completed by male staff.

Where people at the service were living with dementia, we observed the environment did not always reflect best practice to support people with orientation around the home. People were not supported to engage in meaningful activities and appeared to have limited interaction.