ST ELIZABETH

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

At our last inspection, we found breaches in regulation in relation to safe care and treatment, staffing, recruitment and safeguarding.

At this assessment we reviewed 7 quality statements for this key question. We found not enough improvement had been made and there were continued breaches of legal regulations. We identified ongoing concerns with safeguarding, safe care and treatment including managing or mitigating risks to people, environmental and infection control risks, staffing and, pre-employment checks.

Whilst some improvements had been made to the safeguarding processes and the management of medicines, we found concerns had not been fully addressed from our last inspection.

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 have a proactive and positive culture of safety based on openness and honesty. They did not acknowledge or recognise concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service had not demonstrated a learning culture where the provider had implemented measures to ensure people received safe care at all times. The provider had failed to learn lessons from previous inadequate and requires improvement ratings and breaches of regulation. Not enough improvements had been made in the service since our last inspection in August 2024, and the improvements that had been made were not embedded. During this inspection, we identified continuing concerns, which placed people at risk of receiving unsafe care.

Incidents and concerns were not learnt from to prevent future harm. As an example, prior to this assessment we had identified concerns of unsafe practice while the stairlift was in use, which placed people at significant risk of harm. We raised these issues immediately with the management team and they assured us they would take immediate action to address these concerns. However, at this assessment, they were unable to provide us with any evidence to demonstrate actions had been taken or lessons had been learned from the incidents. This meant there was potential unsafe practice would be continued.

Leaders had been ineffective in identifying and driving required improvements to support a learning culture. This included processes in relation to infection prevention and control (IPC) tasks delegated to night staff, where leaders told us changes that they had requested to drive improvement had not been implemented. Leaders failed to ensure staff embraced a positive learning culture.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider did not have robust and safe systems in place for people to transition between services. For example, assessments for a person who was admitted to hospital did not contain essential information such as, the person’s personal care needs, continence needs, nutritional needs and emotional support. It is important to ensure essential information is shared between services and any risks were known and mitigated. The sharing of this information helps ensure the person receives continuity of care in a person-centred way.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Overall, the provider had a process in place to identify and report concerns. We saw information that was appropriately shared with the local authority where they had identified that this was a safeguarding. However, during this inspection we identified concerns that leaders of the service did not always ensure people were appropriately protected from avoidable risk of harm.

We raised 2 safeguarding referrals to the local authority team in relation to the transfers of 2 people from the ground to the first floor and vice versa, due to our significant concerns for their safety. The service had a stair lift in place and not a shaft lift. Both people were unable to mobilise unaided and had been assessed as requiring a hoist for transfers. Leaders of the service told us they supported both people to transfer using the stair lift, however they had failed to demonstrate they had taken appropriate and robust steps to identify and mitigate the increased risks to people during these transfers. We were not assured that correct procedures were followed, which placed people at avoidable risk of harm.

Records reviewed indicated a scalding incident had occurred at the service. Although the registered manager had carried out an investigation of this incident, this was not robust. The registered manager had not taken into consideration audits completed for water temperatures which indicated fluctuating temperatures in the distribution of hot water. We reviewed water temperature records and identified the shower had temperatures captured at 62°C. At the time of our assessment there was no thermostatic mixer valve in place and the registered manager confirmed that temperatures prior to showering were not taken. This meant people were at continued risk of significant harm from burns or scalding.

Staff we spoke with understood who they could raise concerns to. The provider had an appropriate policy and procedure in place.

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.

Risk management plans were not always in place, robust or contemporaneous to reflect the care people required. This included risks associated with the management of people's repositioning, catheter care, fluid intake, early signs of deterioration and inconsistent records.

We found poor management of risks to prevent damage to people’s skin. We saw significant shortfalls in people’s repositioning records and the provider could not demonstrate that people had been supported with repositioning in the timeframe they had been assessed as required to maintain their skin integrity.

Risks associated with people’s catheters were not assessed and planned for. We reviewed records for a person who had a catheter, the care plan did not give sufficient guidance to staff in relation to catheter associated issues. It did describe the catheter being required ‘to monitor the output of urine and prevent further damage to my kidneys’, however over a 28-day period there were gaps noted in urine output on 22 days. This placed the person at increased risk of complications impacting their health and well-being due to ineffective monitoring.

Risks of injury, including entrapment which can result in suffocation or injury, from use of bed rails were not assessed and managed appropriately. A person living at the service had bedrails in place to maintain their safety. However, bedrail measurements were not taken or recorded which put the person at increased risk of harm. We identified additional entrapment risks as one side of a bedrail that was in use was broken and in need of repair.

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

We found significant and widespread shortfalls in the safe management of the environment. There was an absence of appropriate measures to ensure people, staff and visitors accessing the building were appropriately protected. There was a lack of urgency in addressing risks to peoples’ immediate safety, this was demonstrated through the continued concerns highlighted with the environmental risks including the poor state of cleanliness, fire safety, water safety and the security of the home.

Fire safety issues that were identified on our last inspection in August 2024 continued to be a concern on this inspection, such as fire door compromises, gaps in testing records, no record of night staff completing fire drills and not all staff had received fire training.

The provider had ineffective systems to ensure water safety at the service. There was not a robust system in place to ensure oversight of recordings of water temperatures and actions taken when they were outside the safe ranges. Records indicated some outlets distributing water at 62°C putting people at risk of scalding. Some hot water pipework prior to thermostatic mixing valves (TMV) failing to achieve the minimum requirement for control of Legionella bacteria. There were no records to demonstrate annual servicing of the thermostatic mixing valves that were in place, some valves were observed to be very scaled. Scaled taps can create stagnant areas where Legionella bacteria thrive. This placed people at risk of Legionnaires' disease, a serious form of pneumonia.

Call bell buttons were not assessed to meet people’s needs, where they were mobile, so ensure they could summon help. Some people’s call bells remained in a fixed location, for example, by their bed or toilet, meaning if they were walking around their room and fall, they would not be able to reach their bell to summons help.

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.

At our last inspection in August 2024 we identified that leaders were not following safe recruitment processes. The provider had not improved processes and at this inspection we found continued shortfalls in safe recruitment. We reviewed 3 new staff recruitment records and found the pre-employment checks for all 3 were not carried out in line with requirements. This included the lack of pre-employment checks in relation to Disclosure and Barring Service (DBS) checks, obtaining satisfactory evidence of conduct in previous employment concerned with the provision of services relating to health or social care, or children or vulnerable adults and satisfactory verification of the reason why the person’s employment in that position ended. This meant people were at risk of receiving care from staff that had not been proven to be of good character.

The provider’s systems to induct and provide ongoing support to staff in their role were ineffective and not always consistently carried out to ensure staff had the training, guidance and support to carry out their role effectively.

Supervision records showed significant shortfalls in supervisions being completed with staff. This included regular reviews of 3 new staff and their progress during their probation. Regular staff supervision ensures staff are competent and confident to do their role, it also gives the opportunity to discuss learning and development. The providers records identified that staff did not receive supervision and appraisals in line with their policy. In a 12-month period 80 supervisions were due, only 15 had been completed. No appraisals had been completed.

Due to the level of continued concerns in care delivery and practice raised on this assessment, we were not assured that the training provided to staff was sufficient or at an appropriate level to support staff with the correct knowledge, skills and understanding to effectively carry out their role.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider was unable to demonstrate that the systems in place to prevent and control infection were robust or effective. Although cleaning schedules were in place, they were not always completed and proved to be ineffective based on the poor cleanliness of the home. The provider did not provide evidence of an annual infection control statement or a named infection control lead in compliance with best practice guidance. We found significant issues with the cleanliness of the environment and staff practice which demonstrated audits had been ineffective in driving improvement.

During our site visits the environment was observed to be visibly unclean in some areas, including toilets, bathrooms and some bedrooms. Some carpets and soft furnishings were found to have stains and people’s chairs were unclean. A person’s bed was found to be chipped and worn which would make cleaning difficult. There were visible cobwebs in some peoples’ bedrooms and moss growing on the inside of the conservatory roof.

On 3 March 2025 during day 1 of our inspection, we observed a stained and visibly unclean plastic measuring jug in the ground floor bathroom, the registered manager and staff told us this was used to wash peoples’ hair. We requested this be removed however, on 12 March during day 4 of our inspection the jug remained in the bathroom.

Clinical waste was poorly managed, and staff were observed using yellow clinical waste bags in place of red dissolvable bags for contaminated items. Poor hygiene practices were observed. For example, we saw a staff member carrying a yellow clinical waste bag through the home without the appropriate PPE being worn. People were at risk of infection from the practices we observed during our inspection.

On day 1 of our visit, we identified in records that a person had been unwell with vomiting throughout the night and admitted to hospital. During day 2 of our visit, we observed 2 people became very unwell with sudden vomiting. As we had identified a person with vomiting the day before we raised with the provider and registered manager that the service had a potential outbreak of diarrhoea and vomiting. This was later confirmed as an outbreak.

The provider had failed to identify the outbreak in a timely way and before we raised this with them. Therefore we could not be assured appropriate measures had been implemented immediately to prevent further spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

At this inspection aspects of medicines security had improved. However, not all the required improvements and changes had been implemented.

Most relevant medicines had either a date opened, or date removed from the fridge. Therefore, we were assured that medicines were less likely to be administered after their in-use expiry date.

Written guidance to support staff administer "when required" and or "variable dose" medicines had improved and most "when required guidance" was personalised and individualised. However, information to support "variable dose" decision making was lacking. This meant staff or other professionals may not be aware of which doses to administer when where there was a choice, and people may not receive these when they needed them.

Whilst staff told us that a new fridge was to be delivered, the fridge temperature records did not provide assurance that temperature variations were investigated in a timely manner. This meant we could not be assured medicines were stored at the correct temperature.

Peoples’ medicines administration records contained a summary page and a record of medicines administration. The summary included details on how they preferred to take their medicines and their allergies. However, the listed allergies were not always consistent between the summary and the record of administration. This placed people at risk of receiving medicines they were allergic to.