CQC report explained · a residential care home
What the CQC found at Elizabeth House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2021
Elizabeth House is rated Good; inspectors found safe, effective and well-led care, with some mixed feedback about staffing levels.
This was an unannounced, focused inspection on 11 November 2021. One inspector and an Expert by Experience spoke with people, relatives, staff and health professionals, observed care and checked records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found enough staff on duty, safe medicines management, good risk assessments, suitable training and effective quality checks. They also found improvements in how consent was assessed and recorded.
Some feedback suggested staff could not always spend as much time with people as they wanted. The home said it would keep staffing levels under review.
The previous overall rating was Requires Improvement, with a breach about consent. Inspectors found the improvements were sufficient and the home was no longer in breach. Caring and Responsive were not assessed during this focused inspection, so their previous ratings were carried forward.
Consent and choice
The home had improved its mental capacity and consent processes. Inspectors found people’s rights were protected and staff asked for consent before care.
“Improvements had been made and the home met the requirements of the MCA.” from the report
Risk and medicines
People had individual risk assessments and clear instructions for staff. Medicines were ordered, stored, administered and recorded safely.
“People had risk assessments in place for all of their care and support.” from the report
Food and healthcare
People were offered choices at mealtimes and could request alternatives. The home sought medical help in a timely way and recorded professional advice in care plans.
“People were supported to have enough to eat and drink. Mealtimes were relaxed, sociable occasions.” from the report
Quality monitoring
Audits covered areas such as medicines, infection control and care plans. The systems were used to identify and support ongoing improvements.
“The quality assurance systems were used to drive continual improvement throughout the home and organisation.” from the report
Staffing at some times
needs fixingAlthough inspectors found enough staff on duty, some people’s feedback suggested staffing was not always sufficient. This could limit the time staff spend with people, so the home said it would keep staffing under review.
“However, some feedback we received suggested that, at times, this was not the case which meant staff could not spend as much time with people as they wanted.” from the report
- 01How many staff are normally on duty during the day and night, and how do you respond when staffing levels are lower?
- 02How will you make sure residents receive enough individual time and attention when the home is busy?
- 03What is the current position on the application for the manager to be registered with the CQC?
- 04How are consent and mental capacity assessments kept up to date for each resident?
- 05What were the previous ratings for Caring and Responsive, which were not assessed in this inspection?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not assessed and their previous ratings were carried forward. This explanation was written from the published report of 1 December 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2021
Inspected but not rated; infection control problems were found and corrected immediately.
This was an unannounced inspection on 3 December 2020. It was a targeted check of infection prevention and control, carried out because of coronavirus outbreaks in care homes.
Inspectors found that seating in most communal areas was too close together for social distancing. The home also did not have records showing that frequent touch points had been cleaned. The provider corrected both issues immediately.
The home had infection control policies, visitor procedures, personal protective equipment arrangements and routine testing. People were tested before admission, tested again and supported to isolate for 14 days after moving in.
The service was inspected but not rated. This report does not give an overall quality rating or ratings for most areas of care.
Infection control policies
The home had current infection prevention and control and coronavirus policies, along with quality audits.
“The provider had an up to date infection prevention and control policy, covid-19 policy and quality audits.” from the report
Safe admissions
The home tested people before admission and again after they moved in. New residents were supported to isolate for 14 days.
“The provider was admitting people safely to the service.” from the report
Visitor arrangements
Pre-arranged visitors were asked health questions and were provided with masks and hand sanitiser.
“Pre-arranged visitors were welcomed to the home with a procedure that helped to reduce risks of infection.” from the report
Regular testing
The home had routine testing for staff and residents.
“The home had routine testing for staff and for people living at the home.” from the report
Social distancing
needs fixingSeating in most communal lounges and the dining room was too close together. Inspectors said this created a risk of cross infection, and the layout was changed immediately.
“People were at risk of cross infection as the layout in all but one of the communal lounges and the dining room was not arranged in a way that encouraged and supported social distancing.” from the report
Cleaning records
needs fixingThe home could not show that all frequent touch points had been cleaned. A specific cleaning schedule was introduced immediately after inspectors raised this.
“They were not recording the cleaning of all frequent touch points around the home.” from the report
Infection control audit
minorA quarterly infection control audit had not identified the missing cleaning records.
“A September 2020 quarterly IPC audit had not identified this omission.” from the report
- 01How do you now record and check the cleaning of all frequent touch points?
- 02How are communal lounges and the dining room arranged to support social distancing?
- 03How often are your infection prevention and control audits completed, and what happens if they find a problem?
- 04How do you check that new staff complete infection control training before working with residents?
- 05What infection control arrangements currently apply to visitors and new admissions?
This was an unannounced targeted inspection of infection prevention and control practices only, so the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 18 February 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Elizabeth House
3 rated inspections over 5 years: the service has held its Good rating throughout.
- December 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- September 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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