ST ELIZABETH

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

At our last assessment we found the provider was in breach of legal regulation in relation to good governance.

At this assessment we reviewed 7 quality statements for this key question. We found not enough improvement had been made and there were continued breach of legal regulation.

We identified significant shortfalls in the providers governance systems, the processes in place were ineffective to monitor, review and drive improvements. Actions had not been taken to address previous shortfalls that had been identified by Care Quality Commission. We were not assured that the providers governance ensured people always received safe, effective, and responsive good quality care.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider had not established an effective process to support shared learning and embed a clear vision and strategy across the service. Staff did not demonstrate a positive, caring and kind culture which promoted inclusion and compassion towards people. People’s rights were not always upheld, and people were not treated with dignity.

The provider had some relevant policies in place, which included bullying and harassment, ‘Equality Diversity and Human Rights’ and ‘Religion and Belief’ however, there was no effective systems in place to demonstrate staff had read and understood the policies or that these had been embedded in practice.

We reviewed the minutes of two staff meetings and one senior meeting that had taken place over a one year period. The outcome of a recent complaint described for this to be discussed at the next staff meeting however, on review of the meeting minutes, there was no record of the complaint or the desired outcome being discussed with the staff. Therefore we were not assured that the provider had a clear and transparent approach that was shared with staff to support their learning.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We found oversight from leaders where tasks were delegated were not always well-managed. For example, the implementation of IPC processes for tasks allocated to night staff had not been completed. We raised this with a senior staff member who commented, "It falls on deaf ears, I have told them, [deputy] has told them, [registered manager] has told them, but they don’t do it”.

The registered manager failed to ensure staff had received levels of training assessed as necessary to mitigate risk related to people’s care. For example, the registered manager had completed risk assessments detailing how staff had completed training in the use of clinical assessment tools. However, there was no evidence that this training had taken place.

We identified continued breaches of the legal regulations and concerns in areas such as safety of the premises and security. Leaders had not independently identified and acted on these concerns prior to our assessment. Where concerns and issues were brought to the leadership teams’ attention, they did not demonstrate a realistic understanding of the widespread nature and seriousness of concerns identified.

People did not feel they could speak up and that their voice would be heard.

The provider’s whistleblowing policy did not always contain up to date information or contact details for agencies staff could contact to raise concerns. Therefore, we were not assured the provider’s policies and procedures were robust in providing staff the information they needed.

We could not be assured staff were given opportunities to speak up due to the shortfalls we identified in relation to formal supervisions sessions. Furthermore, staff had raised the lack of supervisions in a recent quality assurance questionnaire (February 2025) however, at the time of our inspection the leaders had not taken any action to address this. This demonstrates leaders did not always act on feedback given. As most staff did not have regular opportunities to provide feedback, raise concerns and identify improvements, we were not assured that leaders actively promoted staff empowerment to drive improvements.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us they had a diverse staff team and they would support and respect any considerations that may be needed for staffs’ individual needs but no staff currently required additional support.

Staff we spoke with told us they could have flexibility with their working patterns to support them with other commitments such as parenting needs.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found widespread and significant shortfalls in leadership, systems, processes and oversight of service delivery. Leaders had failed to act on past concerns, had not implemented a robust system to review and improve quality and safety and had not implemented a credible plan to improve.

Systems and processes in place to gain people’s consent and make decisions continued to be ineffective and did not demonstrate care was always provided in line with legal frameworks.

Systems and processes continued to fail to ensure people’s records were always up to date, complete or contemporaneous. We found multiple examples where people’s care records were incomplete, insufficiently detailed or not person centred and did not contain sufficient information for staff to manage people’s specific needs or conditions. Records of people’s personal care did not provide assurances that people’s needs were adequately met or provided in-line with their preferences.

Processes for ensuring staff were suitably skilled and competent continued to be ineffective. Systems and processes related to staff recruitment failed to ensure practices were in-line with legal requirements.

Audits undertaken did not include effective oversight of all relevant best practice guidance. For example, audits completed did not consider relevant dementia friendly guidance or ensure best practice tools such as the use of restore and early detection of deterioration in people’s well-being was appropriately implemented.

The provider failed to ensure all relevant policies and procedures were in place and they did not have effective systems to demonstrate staff had read and understood the policies or that these had been embedded in practice.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

There was a lack of engagement into the local community to engage and support peoples emotional and spiritual needs.

We received mixed feedback from professionals about how well the service worked in partnership with other agencies to drive improvement.

We received mixed feedback from relatives, comments included, “[I’m] now getting more phone calls, I would still like more partnership” and “[I] went to a meeting a few weeks ago, they [leadership] were talking about re-decoration, I said I was more concerned about care and lack of stimulation”.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There was a lack of clear structure and accountability and this meant there was no clear strategy in place to address areas where improvements were needed.

There were 8 breaches of regulation identified at our last visit. At this inspection we found 7 repeated breaches of regulation and an additional breach in regulation around dignity and respect. The provider failed to ensure that improvements from the last inspection had been addressed and the required improvements made to ensure compliance with the legal regulations.

The registered manager told us the provider had supported them to arrange a visit to another care service to support them to learn and share ideas.