ST ELIZABETH

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed a total of 4 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question had deteriorated too requires improvement. We found the provider was failing to meet their legal requirements and were in breach of their legal requirements. We identified significant shortfalls in the providers governance systems, and we were not assured appropriate processes were always in place. Where processes were in place these were ineffective to monitor, review and drive improvements in the service and were not assured that the providers governance ensured people always received safe, effective, and responsive good quality care. The provider also failed to ensure they informed the Care Quality Commission of notifiable events at the service where they were legally required to do so. We spoke with staff who told us they felt supported by leaders of the service.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We were not assured that the provider process always supported effective and inclusive recruitment as they were unable to demonstrate how they met their legal requirements. We were not assured that leader’s at every level always modelled inclusive and appropriate behaviours and led by example. For example, we reviewed safety records where the provider’s processes identified learning from a previous incident of poor moving and handling of equipment which placed a person at risk. During this assessment we observed where a senior staff member continued to demonstrate poor compliance to best practice.

Overall staff told us they had a good relationship with leaders. One staff commented, “I Think [Registered manager] is doing really well, the door is always open, [Registered manager] always appears calm and listens.”.

Overall staff told us they felt able to make suggestions. Staff we spoke with told us that they were comfortable raising concerns to all levels of leadership and felt they would be listened to.

We found the providers policies and procedures in place to support staff in speaking up and raising concerns were out of date and did not reflect all the required information staff would need to be able to do so. These included policies in relation to safeguarding and whistleblowing. We reviewed staff meeting minutes and were not assured leaders of the service always ensured staff were informed of the correct actions they should take to escalate concerns or actively promoted an open culture to ensure staff were informed and encouraged to speak up to organisations outside of the service where they had concerns.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Some staff we spoke with stated they felt that records and updating documents when things change could be improved. When discussing some of the short falls we identified at this assessment leaders could not always demonstrate they had a sound and sufficient understanding of all required responsibilities and legal requirements.

Systems for identifying, capturing and managing organisational risks and issues were ineffective and did not drive improvement. The providers audits and systems were ineffective to identify the widespread and significant concerns identified at this assessment. This included shortfalls for environmental risks, individual risk management, accurate and contemporaneous care records, the need for consent and compliance with safeguarding and statutory requirements. Leaders did not demonstrate that they maintained oversight of delegated tasks, for example delegated tasks in relation to the health and safety of the building. Where records evidenced non-compliance, the provider failed to take actions to address and reduce the risks to people. Leaders completed some monthly audits, such as accidents and incidents and falls analysis, however these were not effective and did not identify multiple examples where the provider had failed to notify the CQC of relevant safety events that occurred at the service or the local authority of relevant required safeguarding information. Systems to ensure staff were sufficiently trained and competent in their role were not effective. The provider failed to have appropriate oversight of the recruitment process and failed to meet their statutory requirements. Governance systems around the need for consent were ineffective. Records lacked consistent information regarding people's capacity to consent to specific decision, and we found there were no mental capacity assessments and best interest decisions for most people where this was required. Oversight of people’s care delivery and records was not adequate to ensure that they received consistent, good quality, person centred care. Systems in place to review people’s care documentation was not robust. We found multiple examples where information in people’s care plans was incomplete, out of date or conflicting.

We received feedback from relatives that communication needed to improve. Comments included, “Just the lack of communication at the moment about which direction the home is going in and who the manager is.” And, “If I had to speak to someone now, I wouldn’t have a clue who to speak to, I would say it’s now 6/10, there seems to be a high turnover of staff at the moment because there seems to be different faces each time I go in there.” We asked relatives if they had opportunities to engage with leaders to share feedback to support improvements to the service and no relative we spoke with had been given this opportunity.

Staff understood the different professional’s people at the service could access support from. However, staff had a limited understanding of how to improve outcomes for people through partnership working. When discussing feedback from people and relatives about a lack of communication, the registered manager acknowledged that they had not had any resident or relative meetings since commencing in the post.

We received feedback from partners that corroborated some of the concerns and shortfalls that we identified at this assessment.

There was limited evidence to show how the provider was meeting this quality statement. Systems in operation had failed to gather feedback from visiting professionals or ensure the service was always working collaboratively. As a result, leaders increased the risk of missing opportunities for learning designed to improve the quality of support people received. Quality assurance questionnaires were not in place to obtain feedback from staff, residents, relatives and professionals; therefore, no outcomes or trends could be analysed. The provider could not demonstrate that they had sought people’s feedback to improve information and learning.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.