ST ELIZABETH

Updated 26 June 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by one inspector.

Service and service type

St Elizabeth is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of the inspection the previous manager had left, a new manager was in place who had applied to be registered. They will be referred to as “the manager” in this report.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority about the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.

We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service and three relatives about their experience of the care provided. We spoke with six members of staff including the manager, deputy manager, senior care worker, care worker and one of the cooks. We observed how staff interacted with people and how people were supported during a mealtime.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We sought feedback from three professionals who worked with the service.

Updated 26 June 2021

About the service

St Elizabeth is a residential care home providing personal care for up to 17 people aged 65 and over who may be living with dementia. At the time of the inspection there were 12 people living at the home.

The home accommodates people in one adapted building with two floors. There is a range of living areas. Bedrooms are spread across two floors; some have ensuite and some have shared bathroom facilities.

People’s experience of using this service and what we found

The service had made improvements to risk assessment processes and management systems which meant people were protected from the risk of avoidable harm. Staff had a good awareness of types of abuse, incidents they should report and how to provide safe support for people. People received their medicines as prescribed and infection control practices were robust.

The service worked with other healthcare organisations to ensure people had support to meet their physical and mental health needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were caring and compassionate. People were treated with kindness and respect. Staff understood how to promote independence and meet people’s individual needs. People described staff as “very good” and “lovely”.

There had been improvements to the activities available to people so that they were more personalised. Staff had more time to spend one-to-one with people, to prevent anxiety or distress and to keep people occupied. There had been no formal complaints in the past 12 months. People and their families were asked for their feedback regularly and were kept up to date.

Staff understood how to provide compassionate end of life care and knew people well, though advanced care plans were not detailed. This continued to be a recommendation for the provider to implement best practice.

The provider had improved connections with the local community and other stakeholders, particularly during the pandemic. There had been considerable improvements to the quality assurance in the service which meant any issues had been identified and there was a clear plan of action for continuous improvement. Staff, people and relatives fed back positively about the provider, the manager and the senior staff and felt there was a positive culture in the home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 1 May 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

At the last inspection of the service breaches of legal requirements were identified relating to person-centred care; need for consent; safe care and treatment; good governance and staffing. The provider completed an action plan after the last inspection to show what they would do and by when to improve. We met with the provider and directed them to support available to make the required improvements.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Elizabeth on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.