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

People were not always kept safe or have risks to their health and wellbeing recognised and action taken to reduce ongoing risk. The home environment had posed a risk to people; areas which should have been secured were open to access and could have caused people harm, some pipes which could become hot were exposed and many areas and items of furniture were damaged. Some areas could not be kept hygienically clean due to their condition so posed an infection control risk. Systems in place to identify and learn from incidents were ineffective. There were a lack of clear systems to monitor people’s health conditions. Care plans did not always have enough or correct information about how to support people. Feedback to address concerns and make improvements was not always swiftly acted on. Staff understood their safeguarding responsibilities; however, the systems in place to ensure safeguarding concerns were dealt with was not always clear. Staff did not always check consent with people prior to supporting them. We observed people were not always supported safely during moving and handling. Training for staff needed improving to help them to be effective in their roles. There was mixed feedback from people and relatives about staffing levels. Some felt there were enough staff, whereas others felt more were needed. The provider had recently increased staffing levels in response to feedback. People’s medicines had not all been managed safely which had put people at risk, although people did not raise any concerns with us about this. There was a lack of appropriate guidance in place for staff to follow about some medicines. Despite this, people told us they felt safe. People and relatives felt the home was clean and tidy. Staff told us they knew people well.

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.

People did not share any feedback with us about Learning culture.

The nominated individual was aware and understood of the need to learn from things that go wrong. However, as the provider had failed to act on feedback in a timely manner prior to our assessment, we could not be sure this would always be the case.

We could not always be sure people were kept safe and there was learning from incidents. The provider did not have effective systems in place to ensure incidents were recognised and learning taken to reduce the risk of a reoccurrence which had left people at risk. One person who required supervision in the community had left the home unaccompanied without staff knowledge on 4 separate occasions. This meant lessons had not been effectively learnt to prevent these incidents from reoccurring. The provider took action after each individual occasion to secure the point the person left the home by, however measures to effectively monitor the person to reduce the risk of them leaving the home unaccompanied had not been effective. Accidents and incidents were not always recorded effectively, so there was a risk they may not be reviewed as needed. Staff did not always records incidents on corresponding forms, but the review carried out by the registered manager only reviewed these forms, so some concerns may not be reviewed and themes or learning identified. The form in use to analyse information was not always fully complete or not always completed correctly, so we could not be sure these reviews of accidents and incidents was effective.

People did not share any specific feedback with us about Safe systems, pathways and transitions.

Staff did not have any feedback to share in the area of Safe systems, pathways and transitions.

The local authority had visited the service multiple times to check people were safe and to check the provider was acting on feedback to make improvements to the service. However, they continued to find ongoing concerns. Referrals were made to other professionals, to support the service and ensure people had personalised care. This was often prompted by professionals visiting the service, rather than the provider being proactive in its approach and recognising when additional support was needed such as with occupational therapists or pharmacists.

The provider did not have processes or individualised plans in place about how and when to escalate concerns if a person had not opened their bowels. One person had been noted on their medicine records as being given a ‘when required’ constipation medicine regularly for a period of over 3 weeks but this had not prompted a referral to check whether their persistence of symptoms was a risk, or not. Following our feedback, the provider checked their records, and the person had opened their bowels, so this reduced the risk to the person. However, as there was a lack of processes to identify this for all those at risk of constipation on an ongoing basis, this still left people at risk of becoming seriously unwell. There was not a robust process in place to ensure the kitchen staff had the most up to date and correct information about people’s dietary needs. Some lists about people’s needs were in place; there was a list for people’s fluid targets, allergies and those who had diabetes. However, these lists were undated and there was not an effective process in place to ensure these remained up to date. We were told information about people’s modified diets (such as those who needed different consistency food) was shared with the kitchen verbally rather than being recorded in a clear, written format for kitchen staff to consistently access and refer to. This meant there was not a robust system in place to ensure relevant staff had access to clear information regarding people’s needs, which could lead to errors.

People told us they felt safe. One person said, “I am very happy with the service they give. It’s just a friendly place and I’m happy. If there was something I wanted to talk about I would ask any member of staff.”

Staff were aware of different types of abuse, how to recognise this and their safeguarding responsibilities to report concerns.

We observed staff did not always check consent or explain things prior to supporting people, such as during moving and handling or checking prior to putting food protectors on people at lunch time, for example.

The systems in place to monitor and track safeguarding referrals were chaotic. There was a folder in place to store safeguarding records, however the tracker the provider had in place was not always completed with details about the referral. Also, as incidents were not always effectively recorded, we could not be sure concerns would always be effectively identified. While staff understood their responsibilities to recognise and report concerns, we identified concerns about the approach of some staff and concerns with 1 person’s care plan, these issues showed a lack of understanding by some staff. One person had a care plan in place that stated they had mental capacity, but then also referred to the person having a Deprivations of Liberty Safeguards (DoLS) referral in place. A DoLS only applies when a person no longer has capacity to make particular decisions. This care plan had been reviewed and this discrepancy had not been identified, so there was a risk staff were not fully aware of the protections in place to protect people’s rights. The provider acted on our feedback after the inspection. They told us they had updated this person’s care plan. We will check processes have improved at the next inspection.

People told us they felt safe while staff were supporting them.

We asked staff about people’s needs, and they were generally able to tell us about these.

We observed people were not always supported safely with moving and handling. One person had their feet knocked while another person was being supported. People were not always supported in the best way at lunch time. Staff would support 2 or more people at a time, which meant there was a risk from an infection control perspective, as well as a dignity and potential choking risk.

People were not always being kept safe. People’s health and wellbeing were put at risk due to poor risk management and poor moving and handling. We were told by a staff member, and the local authority, of an incident where a person had been poorly supported with moving and handling which caused the person discomfort. Staff did not always explain each stage of the moving and handling they were supporting people with. This did not always allow people to partake in managing their own risks while being supported through processes that placed them at risk such as during moving and handling and staff were not demonstrating they were caring. People’s care plans were not always fully up to date and accurate. For example, some people were at risk of constipation, but their plans did not detail all measures in place which could leave them at risk. Another person had a health condition which meant they had a monitor in place, which staff knew they would need to respond to should the monitor alarm. However, this was not clearly referenced in their care plan. As there were agency staff in use, who may not be as familiar with people’s needs as permanent staff, so it was important they had access to the full information about people’s needs.

Relatives consistently told us they felt the home needed redecorating, although they felt individual bedrooms were kept clean.

Staff felt the home needed redecorating. One staff member said they would want bedrooms redecorating and to get rid of the wallpaper in people’s rooms and bathrooms. We discussed damage to the décor with the provider. They explained they had attempted to engage external contractors to carry out environmental improvements but that had proved difficult, and they had been let down so had not managed to resolve this.

There were multiple unlocked cupboards containing items which could pose a danger to people, in areas people could access. Window restrictors were in place, but they were not always tamper-proof which could put people at risk. The flooring in multiple bathrooms was not appropriately fitted so there was exposed wood or flooring underneath. A communal bath was unsealed around the edge. Some equipment had damaged coating, so the metal was rusted underneath. The light in 1 person’s en suite was broken with the wiring exposed. All of these posed a risk to the health and safety of people. The environment was tired and in need of refurbishment, the décor was damaged throughout the building and due to damaged surfaces on furniture, wallpaper, and fittings, they could not be kept hygienically clean so left people at risk.

Systems in place failed to identify and address the environmental issues we found. There was a maintenance book in place for staff to record things that needed fixing however this had not resolved all the concerns we found. Some concerns had not been identified and addressed in audits or in the maintenance book. People had also fed back in a residents meeting in February 2024 they felt the home needed redecorating and, while some redecorating had been done, this was not effective, and the majority of areas still needed a lot of work.

People and relatives told us they thought the permanent staff knew what they were doing. One relative told us they thought the permanent staff appeared trained, but the agency staff did not appear trained. Feedback from people and relatives was mixed about staffing levels. One person said "I press my buzzer. Staff are slow to come sometimes and then they ask if I can wait. They’ll ask me to wait 5-10 minutes but sometimes it’s longer. It’s a long time [referring to needing the toilet].” One relative said they felt there may be some staffing issues as their relative had to wait to go to bed. The relative explained they felt their loved one thought they were always the last to go to bed and being told to wait, but they did not always understand this. Another relative told us they felt staffing levels occasionally seemed to reduce at the weekends but did not have a concern about this and they felt generally there were enough staff. The staffing levels had recently been increased by the provider in response to feedback from the local authority.

There was mixed feedback about training. Multiple staff confirmed they had received training and felt it was sufficient. They told us it was a mix of face to face and online training. However, one staff member said, “Residents are too complex for staff we’ve got and the training we’ve had.” Staff generally felt there were enough staff on each shift. One staff member said, “I feel that there is enough staff on a shift, there is always someone to assist me if I need it.”

We observed people were not always supported appropriately with moving and handling. There were also issues with medicines and personalised care. Therefore, this showed staff training was not always effective to ensure they were confident and competent to support people. Moving and handling training needed improving and further training would have been beneficial to ensure people received person-centred care.

Effective systems were not in place to identify staff training in moving and handling was not always effective or consistently practiced by staff. Records showed staff training was not always up to date. It was not clear how the provider decided what training was needed for each staff member, as some staff had had completed some training whereas others had not been assigned the training to complete. Not all staff who the provider had identified as requiring food hygiene training had completed this, and no staff had received person centred care training, despite this being listed as a course available for staff. Our observations showed some staff would have benefitted from person-centred care training.

Relatives felt the home was clean and tidy.

Staff told us there were domestic staff 7 days a week, with 1 day there were 2 domestic staff present, which they felt was enough.

The home was not always clean. Some chairs people sat in in communal areas were dirty. Areas of the home were damaged, and paint and wallpaper was peeling off some walls. Furniture was damaged. Therefore, these areas could not be kept hygienically clean. Light pulls in some bathrooms were dirty and were not able to be cleaned, which put people, staff and visitors at risk of cross infection. Radiator covers were not coated or painted and were an exposed wood surface so they could not be kept clean.

The provider’s policies and processes to ensure the home was sufficiently cleaned and as often as necessary had not been effective due to the number of concerns we found. The provider’s systems to monitor this had also not been effective at identifying where further cleaning, repair or other improvements were needed. People had been exposed to the risk of cross infection by poor cleanliness in some areas of the home, damaged areas of furniture and surfaces which could not be kept clean and by uncoated/covered fixings which could also not be kept clean. It was also not dignified for people to reside in unclean environments. Following the inspection, the provider shared with us the audit report from the NHS Infection Prevention and Control team which showed some improvements had been made following the inspection. This showed the provider had improved from a ‘red’ score to an ‘amber’ score. We will check these improvements had continued and been sustained at our next inspection.

People raised no concerns with us about their medicines. One person said, “Staff bring it [medicine] in the morning and afternoon and nighttime. It’s more or less the right time. I’m not aware of any mistakes.”

A staff member acknowledged there were areas to improve with medicines and they had planned to carry out full audits on medicines to determine the areas for improvement. They also felt as there had been a lot of intense and frequent feedback from external professionals, it was taking time to embed new processes with staff. Staff did not give us any specific feedback about medicines processes. One staff member confirmed they did not hide medicines, so people were always informed they were being given medicine.

People had been put at risk as medicines were not always safely managed. Records were regularly poorly completed so we could not be sure people were receiving their medicines as prescribed, which could put people at risk. In addition to this, 2 people had been overdosed based on their prescription and this had not been recognised. Another person had one of their medicines delayed by a day without an explanation and it was not clear this had been noticed. Medicines taken ‘when required’ did not always have enough or correct guidance in place for staff to know when this was needed. There were issues with the recording of ‘when required’ medicine so we could not be sure these were being given as prescribed. Staff were not always recording the doses of medicines given, when a variable dose had been prescribed. This left people at risk of receiving too much or not enough of their medicine. As mentioned, there was intense scrutiny of the provider by a range of visiting professionals at the time of our inspection, which the provider told us they felt this contributed to some of the issues with ‘when required’ medicine in the home, as some feedback had been contradictory. Following the inspection, the provider told us they updated people’s ‘when required’ protocols and we will check this the next time we inspect the service. There were no stock control processes in place, so the provider had no way of tracking whether the stock levels in the home matched records, in order to verify people were having their medicines as prescribed.