CQC report explained · a residential care home
What the CQC found at Elizabeth House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Requires Improvement; inspectors found kind care and enough staff, but environmental safety, infection control and management checks were not effective.
This was an unannounced, focused inspection on 29 November 2023. Inspectors spoke with people, relatives and staff, and checked care, medicine, recruitment and management records. They also looked around the home.
The home was rated Requires Improvement overall, and for Safe and Well-led. Inspectors found problems with cleanliness, maintenance and equipment storage. These included a blocked fire exit, an unlocked boiler room with uncovered hot pipes, and some areas needing deep cleaning.
People and relatives generally spoke positively about the care. Inspectors found enough staff, safe recruitment, safeguarding training and support with medicines, although records for rotating pain-relief patches were not always complete.
The home was rated Good at the previous inspection. Because this inspection only looked at Safe and Well-led, the other ratings were carried over from the previous inspection. The provider said it had already made some repairs, improved cleaning and strengthened its monitoring systems.
Enough staff
Inspectors found enough staff on duty, including for people who needed one-to-one support. Relatives said people did not have to wait long.
“There seems enough staff. You do not have to wait. You see the same staff all the time.” from the report
People felt safe
People and relatives said they felt safe and staff knew how to report safeguarding concerns.
“People told us they felt safe living in the home.” from the report
Respect for choices
Inspectors found that staff supported people to make daily choices and worked within the principles of the Mental Capacity Act.
“Staff empowered people to make their own decisions about their care and support.” from the report
Learning from incidents
Accidents and incidents were investigated, discussed with staff and used to look for lessons and trends.
“Incidents were reviewed in team meetings and lessons learnt were shared with the staff team.” from the report
Unsafe environment
seriousThe home needed better maintenance and cleaning. Equipment partly blocked a fire exit, and an unlocked boiler room contained uncovered hot pipes.
“Trollies were being stored in a corridor which partially blocked a fire exit.” from the report
Weak infection control
seriousSome areas needed deep cleaning and a shared bathroom was being used to store wheelchairs. Cleaning checks did not reliably identify or correct these problems.
“Some areas of the home required deep cleaning. Staining was evidence on skirting boards, walls, doors, and light switches.” from the report
Medicine records
needs fixingRecords did not show that pain-relief patches were always rotated according to the manufacturer's guidance. The registered manager changed the monitoring system immediately.
“Where people required the administration of pain relief through patches, records did not demonstrate they were being rotated in line with manufacturer guidance.” from the report
Quality checks missed risks
seriousAudits did not reliably identify environmental problems, missing risk assessments, outdated care information or how long people waited for call bells to be answered.
“Quality monitoring processes had not always ensured risks to people were being identified and mitigated.” from the report
- 01What repairs, redecoration and deep cleaning have been completed since the inspection, and how are you checking that standards stay high?
- 02How are fire exits kept clear and how is access to the boiler room controlled?
- 03How do you now check that pain-relief patches are rotated correctly and recorded?
- 04How do you monitor call-bell waiting times and respond if people wait too long?
- 05Who is responsible for the home when the registered manager is working at the other service, and how is this oversight checked?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 19 January 2024 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, September 2022
Elizabeth House is rated Good overall; inspectors found safe care and good leadership, with some areas needing refurbishment.
This was an unannounced focused inspection on 4 and 9 August 2022. One inspector spoke with people, relatives and staff, and checked care records, medicines records, staff files, training information, policies and audits.
The inspection looked only at Safe and Well-led. Both were rated Good. Inspectors found enough safely recruited staff, safe medicines management, suitable risk assessments and effective checks after accidents or incidents.
The home had a positive, person-centred culture. People and relatives could give feedback, and managers used audits and investigations to make improvements. Some areas needed refurbishment to help keep them clean, and the provider had planned this work.
The overall rating stayed Good, as the ratings for the areas not inspected were carried forward from the previous comprehensive inspection. The previous overall rating was also Good.
Safeguarding
Staff were trained to recognise and report abuse. People and relatives said they felt safe and that staff responded to concerns.
“People were supported by staff who were trained to recognise and report any harm or abuse.” from the report
Safe medicines
Medicine records were complete and staff had clear instructions for medicines given only when needed.
“People's medicine administration records had been fully completed and there were clear protocols in place for staff to follow where people were prescribed medicines on an 'as required basis'.” from the report
Positive culture
Inspectors found the approach was person-centred and inclusive. Staff described management as available and supportive.
“Managers and staff demonstrated a positive culture which was person-centred and inclusive of the people who lived in the home.” from the report
Listening to feedback
People, relatives and staff could suggest improvements. A key worker role was being trialled after people raised concerns about who to contact when the office was closed.
“People, their relatives and staff confirmed they had the opportunity to provide feedback about the service and make suggestions for improvements.” from the report
Refurbishment needed
needs fixingInspectors were only mostly assured about the layout and hygiene of the premises because some areas needed refurbishment. The provider had planned work including painting skirting boards and replacing bathroom floors.
“Some areas required refurbishing to help keep them clean.” from the report
Late notifications in the past
needs fixingThe provider said it had recently been behind with reporting notifiable events to the CQC. It had reviewed its processes by the inspection.
“The provider confirmed they had recently been behind in completing their notifications to us.” from the report
- 01Which areas needed refurbishment, and has all the planned work now been completed?
- 02How do you make sure important events are reported to the CQC within the required timescales?
- 03What did the previous comprehensive inspection say about Effective, Caring and Responsive care?
- 04How does the key worker trial work, and who can relatives contact when the office is closed?
- 05How are accidents and incidents reviewed, and what changes have been made as a result?
This was a focused inspection of Safe and Well-led only; the other ratings and the overall rating were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 17 September 2022 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
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Goodstayed GoodSafe: GoodWell-led: Good
- April 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- November 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 9 March 2011.
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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