CQC report explained · a nursing home
What the CQC found at Queen Elizabeth Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2023
Queen Elizabeth Care Centre is rated Requires Improvement; inspectors found kind care and some progress, but ongoing safety, care planning, consent and management concerns.
This was an unannounced follow-up inspection on 26 January 2023. Inspectors spoke with people, relatives, staff and health and social care professionals. They observed care and reviewed care plans, medicines records, staff files and management records.
The overall rating improved from Inadequate to Requires Improvement. Caring improved to Good. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. Inspectors found improvements in staffing, staff training, kindness, involvement in meetings and the new care planning system.
Important problems remained. Risk assessments and turning records were not always reliable. Medicines were not always recorded safely. Some care plans lacked personal detail, activities were limited, and the Mental Capacity Act was not always followed. Management audits were new and had not yet shown that they were effective.
The home had been in special measures since September 2022 and is no longer in special measures because it was no longer rated Inadequate overall or in any key question. However, it remained in breach of four regulations and the CQC said it would continue to monitor progress.
Kind and respectful staff
People and relatives described staff as kind. Inspectors saw staff respecting privacy, asking permission and supporting people to make choices.
“People and their relatives told us staff were kind and caring.” from the report
Improved staffing
Staffing levels had improved and were considered appropriate for the people being supported on each floor. Staff appeared relaxed and were not rushed.
“We found improvement had been made since the last inspection, each floor of the home had staffing levels appropriate to the people they were supporting.” from the report
Food and healthcare support
Staff knew people's food and drink needs and preferences. The home also worked with health professionals and helped people arrange healthcare appointments.
“The kitchen staff were aware of people's preferences and texture modified diets.” from the report
Improved involvement and culture
People, relatives and staff were more involved in meetings and decisions. The home had introduced regular resident and staff meetings.
“Since our last inspection regular resident and staff meetings had been introduced.” from the report
Some personalised activities
Although activities were limited overall, some people were supported to join activities and take trips into the community. Records showed a positive effect on wellbeing.
“The activities team had also introduced a 'resident of the day' where they took a person on an activity out in the community.” from the report
Risks were not always managed
seriousInspectors saw occasions when a person who needed two staff was supported by only one. Repositioning records also showed fewer turns than required, increasing the risk of skin damage.
“People were not always kept safe from the risk of harm and safe infection prevention and control practices were not being followed.” from the report
Medicines records were incomplete
seriousSome medicines did not have clear instructions or body maps, and stock records for homely remedies were inaccurate or missing. This could mean medicines were given without a reliable record.
“Systems had not been established to monitor all areas of medicine management. This placed people at risk of harm.” from the report
Consent rules were not followed
seriousSome restrictions, including locked doors and bed rails, did not have the required decision-specific capacity assessments or best-interest decisions.
“The principles of the Mental Capacity Act 2005 had not been followed.” from the report
Care plans lacked personal detail
seriousSome assessments and care plans did not record people's choices, needs, life histories or preferences clearly. The new system was better but had not yet been completed for everyone.
“Systems had not been established to ensure people's individual needs and choices were assessed effectively.” from the report
Activities were limited
needs fixingPeople sometimes spent long periods in chairs or private rooms. Inspectors saw little activity and found that available activities did not always match people's interests.
“Since our last inspection the provider had recruited activities staff. However, during the inspection there was very little in way of activities happening.” from the report
Management systems were not embedded
needs fixingNew audits and improvement systems had not been in place long enough to prove they worked. Some audits had failed to identify concerns found by inspectors, and not all staff had regular supervision.
“A number of audits had been introduced to address the concerns found in the last CQC inspection and visits from the local authority.” from the report
- 01How will you make sure each person's risks are recorded accurately and that required repositioning and two-person support happen every time?
- 02How do you check that all medicines, creams, body maps, stock and 'as and when required' instructions are recorded correctly?
- 03How will you make sure capacity assessments and best-interest decisions are completed before restrictions such as locked doors or bed rails are used?
- 04When will my relative's care plan include their life history, preferences, choices and individual needs in enough detail for all staff to follow?
- 05What activities are available that match my relative's hobbies, interests and cultural preferences, and how will you check that they are taking part?
This was an unannounced follow-up inspection covering all five key questions, including infection prevention and control, after the previous Inadequate inspection. This explanation was written from the published report of 31 March 2023 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, January 2023
Queen Elizabeth Care Centre was rated Inadequate and placed in special measures; inspectors found serious safety and management failures.
This was an unannounced inspection on 11 July 2022. Inspectors spoke with people using the service, relatives and staff. They observed care and checked care records, medicines records, staff files and management records.
Inspectors found that people were not consistently protected from harm. Risk assessments and care plans lacked important details, medicines records were incomplete, staffing was sometimes insufficient, and unsafe moving and handling was observed. There were also infection control concerns.
People did not always receive person-centred care or enough emotional support. There were very few organised activities, and some people said they were bored or lonely. The home had no registered manager at the time, and audits and previous improvement plans had not dealt with known problems.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while effective, caring and responsive were rated Requires Improvement. The service was placed in special measures, which means CQC will keep it under review and normally reinspect within six months.
Access to healthcare
Inspectors saw evidence of health referrals and said staff supported people to arrange appointments and follow up results. The home also had a regular weekly GP round.
“We saw evidence of health referrals in people's care plans.” from the report
Meal choices
Staff supported people to choose their meals and used show plates to help people understand the options. People told inspectors they enjoyed the food and drinks.
“Staff used 'show plates' to show people different options at mealtimes and made sure they understood their choices.” from the report
Privacy and dignity
Inspectors saw staff knock before entering rooms and ask permission. They also observed some discreet support that helped maintain people's dignity.
“We saw staff knock on people's door and ask for permission to enter people's rooms and respecting people's privacy.” from the report
End of life planning
End of life care plans had been added to people's care records and included their wishes for this stage of life.
“People had end of life care plans detailing what their wishes were if they entered this period of their lives.” from the report
Safeguarding awareness
Staff knew how to respond to safeguarding concerns, and safeguarding and whistleblowing training had been completed.
“Staff were knowledgeable about how to respond to safeguarding concerns.” from the report
Risk management
seriousRisk assessments did not consistently tell staff how to reduce risks such as choking, falls, diabetes and behaviours that could become aggressive. Inspectors also observed people being moved using a dangerous drag-lift technique.
“People were not kept safe from the risk of harm.” from the report
Medicines
seriousMedicine administration records had gaps, pain patch locations were not always recorded and some as-needed medicine protocols were missing or not reviewed. Inspectors said this increased the risk of medicine errors.
“Systems had not been established to manage medicines in a safe way.” from the report
Staffing levels
seriousThere was a lack of permanent staff and high agency use. Agency staff sometimes arrived late or did not attend, leaving some shifts below the home's planned staffing level.
“There was a lack of permanent staff and a high level of agency use.” from the report
Person-centred care
seriousCare plans lacked details about people's life histories, hobbies, routines and preferences. Agency staff therefore did not always have enough information to provide individualised care.
“The lack of person-centred care was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Activities and loneliness
needs fixingThere was no activities worker or co-ordinator, and very little organised activity. People were seen sitting without stimulation and reported feeling bored, lonely or excluded.
“The management team confirmed there were no scheduled interviews for a replacement at the time of the inspection and very little organised activities were happening.” from the report
Management oversight
seriousAudits were missing or ineffective and did not identify the problems found during the inspection. The provider had not ensured that the previous action plan was implemented.
“Audits were in place however, had been ineffective in identifying concerns we found at the inspection.” from the report
- 01What has been done to make risk assessments and care plans detailed enough for permanent and agency staff to follow?
- 02How are medicines now checked, including gaps in medicine records, pain patches and as-needed medicines?
- 03What staffing levels are being provided on each floor, and how are missed or late agency shifts covered?
- 04Who is responsible for activities now, and what regular activities are available for people with different hobbies and abilities?
- 05What conditions has CQC placed on the registration, and what evidence can you show that the required improvements are complete?
This was an unannounced inspection that covered the care provided and premises under all five key questions, including infection prevention and control. This explanation was written from the published report of 26 January 2023 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 Queen Elizabeth Care Centre
3 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2023Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2021Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- March 2021
Registered with the Care Quality Commission on 30 March 2021.
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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