Elizabeth Court

“Our inspection identified that care plans and risk assessments were not consistently accurate or sufficiently detailed to ensure people’s safety. Additionally, care plans did not always reflect individuals’ preferences or choices.”

“We found that people’s nutritional needs were not always correctly recorded, which increased the risk of choking or aspiration.”

“The provider was not fully adhering to the principles of the Mental Capacity Act 2005. There was insufficient evidence to demonstrate that all reasonable steps had been taken to support individuals in making their own decisions. Furthermore, where decisions were made on behalf of individuals, appropriate documentation to show these were made in their best interests was not always in place.”

“People were not consistently repositioned in accordance with their assessed needs, placing them at risk of skin breakdown.”

“Personal Emergency Evacuation Plans (PEEPs) were found to be inaccurate, potentially compromising individuals’ safety in the event of an emergency evacuation.”

“Staff did not always have the necessary training to support people safely and effectively.”

“Medicines were not always managed safely. Protocols for administering ‘as required’ (PRN) medicines lacked sufficient detail to guide staff on appropriate dosage and timing. In cases where medicines were administered covertly (e.g., hidden in food or drink), there was no evidence that professional advice had been sought to ensure safe and effective administration. This is particularly important, as some medicines can lose their effectiveness or become harmful when mixed with certain foods or drinks. These issues placed people at risk of not receiving their medication safely or appropriately.”

“Governance and quality systems were not effective to assess and monitor the care and treatment provided within Elizabeth Court.”

“The provider was previously in breach of legal regulations in relation to safe care and treatment and good governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations. ​Additionally, we identified a new breach of Regulation 9, relating to person-centred care.”

“This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of care they provide.”

“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.”