ST ELIZABETH

Ratings

• Overall

  Requires improvement

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Good

• Responsive

  Requires improvement

• Well-led

  Requires improvement

Our view of the service

Date of assessment 09 August to 19 September 2024. St Elizabeth is a care home that can accommodate up to 17 people. At the time of our assessment 16 people were living at the service. We undertook this risk assessment following information of concern we received about this service. We assessed a total of 15 quality statements across safe, effective, and well-led key questions and have combined the scores for these areas with scores from the last inspection. At this assessment we found the provider was in breach of 8 regulations. We found significant concerns and were not assured that people always received safe, effective, good quality care. The provider failed to protect people from abuse and did not always share safeguarding information that was required. Risks to people and health and safety risks were not always assessed or safely managed. People’s medicines were not safely managed, and medicines practices were not in line with national guidance. We were not assured staff always had the skills, knowledge and training to meet people’s needs. There were significant shortfalls in the providers recruitment practices, and they could not demonstrate they met their legal requirements. Risk management plans were not always in place, robust or contemporaneous to reflect the care people required. Where people lacked capacity and care was provided in their best interest, practices were not undertaken in-line with legislation. We were not assured people consistently received person-centred and appropriate care that was responsive to their needs. The provider failed to notify the commission of safety events where they were required to do so. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. For some of the breaches identified we have asked the provider for an action plan in response to the concerns found.

People's experience of this service

Overall, we received mixed feedback from people and relatives about their experience of the care provided. Whilst people generally felt staff listened to them and provided support to manage their medicines and daily routines, we received feedback that people could experience delays in receiving their care and people did not always feel there were enough staff available to provide good quality care. During the assessment we found significant shortfalls in people’s experience of care which needed to improve. This included an example where we observed a person cared for in bed was unable to seek staff support when they needed assistance due to the call bell equipment being faulty. We also reviewed people’s personal hygiene records and were not assured people received regular baths, showers or oral hygiene support. We made observations at this assessment and found elements of care did not always meet the expected standards. Shortfalls included observations of people’s dining experience, and we found staff did not always ensure food served was in-line with people assessed dietary needs and risk management requirements. People’s experience of care was not always person centred and where people at the service were living with a diagnosis of dementia, we observed the environment did not always reflect best practice guidance to support people with orientation. We received feedback from people that choices were limited, particularly around main meals and opportunities for meaningful activities. We reviewed records and found care plans did not provide sufficient person-centred information to ensure care provided was always responsive to meet people’s needs. We received feedback from people that communication needed to improve, and they did not always know who the manager was following changes at the service.