Date of assessment: 29 May to 16 June 2025. We undertook an inspection of St Elizabeth’s Domiciliary Care Agency on 29 May 2025, 5 June 2025, and 9th June 2025. At our last inspection, the service was rated as requires improvement (Published 10 January 2023). This was the first inspection carried out under our single assessment framework and was unannounced. This inspection was prompted by a review of the information we held about the service and intelligence. St Elizabeth Domiciliary Care Agency provides personal care for people in their own homes. The service supported people with a learning disability and autistic people. At the time of our inspection there were 25 people being supported with the regulated activity of personal care. We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic. The service met this guidance. We spoke with 10 staff members. This included support workers, managers and senior leaders. We spoke with 2 professionals that supported the people living at the service. People felt safe and were supported by staff who understood their individual needs. Risk assessments were person-centred and regularly reviewed. Safeguarding procedures were well understood and followed. Staff were well-trained and worked collaboratively with health and social care professionals. People were supported to make informed choices and maintain their health and wellbeing. People were treated with kindness and respect. Staff built trusting relationships and supported people in a way that promoted dignity and emotional wellbeing. Support was tailored to each person’s preferences and regularly reviewed. People were encouraged to pursue interests and maintain important relationships. Feedback was welcomed and acted upon. People and staff felt listened to and involved. The service had a positive and inclusive culture. Leadership was visible and approachable, and quality assurance systems were in place to monitor and improve care. The provider was previously in breach of the legal regulation in relation to safe care and treatment, person centred care and good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.
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St Elizabeth's Domiciliary Care Agency was rated Inadequate across safe, effective and well-led domains following a focused inspection in December 2021, with regulatory breaches across Regulations 9, 12, 17 and 18 covering unsafe medicines management, inadequate risk and care planning, non-person-centred care, and failed governance. The service was placed in special measures, with enforcement conditions applied to its registration due to widespread and significant failings that placed people with learning disabilities and autism at avoidable risk of harm.
Concerns (15)
criticalMedication management: “Medicine errors would be a concern. This has been raised a couple of times. There should be no reason why people are running out of meds and at times this happens.”
criticalMedication management: “Only 17% of staff were trained to administer emergency intervention medicines.”
criticalSafeguarding: “Where safeguarding's were identified, these were not always sufficiently prioritised...suggested improvements had not been embedded. This meant that people continued to be at risk.”
criticalCare planning: “People's risk assessments were not clear or coordinated with the information stated in the care plans...someone had been identified with a choking risk, this was not clear in the care plan or risk assessment.”
criticalStaffing levels: “Due to staff changes a staff member was on their own...a person put their hand on the hob of the oven. This person's risk assessment indicated they should have one to one support.”
criticalPerson-centred care: “The service provided 'blanket rules' which resulted in inappropriately restricting people's choice and control. For example, the service locked bathroom doors so they could not be accessed freely.”
criticalGovernance: “The provider and registered manager did not have a robust quality assurance system in place...the management team did not have clear oversight that these were actioned.”
moderateStaff training: “People did not always receive support from staff who had the relevant training, including around learning disability, autism, mental health needs and human rights.”
moderateSupervision / appraisal: “Staff supervision records were not consistent, and staff felt there needed to be more team meetings. I have not been asked once in the last 6 months how are you doing by my bungalow manager.”
moderateIncident learning: “There was a lack of shared lessons learnt with the whole team...the registered manager gathered information relating to accident and incidents, however, did not effectively look at the overall trends and themes.”
moderateConsent / capacity: “We found example of where staff did not look at the least restrictive practice. There was a lack of consideration in protecting and promoting people's rights.”
moderateCommunication with families: “There is a serious problem with management. They don't communicate and they are short staffed.”
moderateInfection control: “We observed staff not following government guidance when using personal protective equipment (PPE)...staff were deployed across all of the supported living services and did not cohort staff teams.”
moderateRecord keeping: “People's care records were not always updated in a timely manner when changes were made by healthcare professionals.”
moderateLeadership: “The management team had not recognised support practices did not promote person-centred, open and empowering care...We found staff using parts of people's kitchens for their own property.”
Strengths
· Staff spoke compassionately about the people they supported and were observed as kind and patient when providing support.
· People were supported by staff who had completed a recruitment selection process including pre-employment checks, references and DBS checks.
· The provider had an internal therapy team including occupational therapy and speech and language available to people.
· Some relatives reported feeling their family member was safe and that managers were visible and approachable.
· Staff were knowledgeable about how to raise safeguarding concerns.
Quality-Statement breakdown (13)
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Learning lessons when things go wrongInadequate
safe: Preventing and controlling infectionInadequate
safe: Staffing and recruitmentInadequate
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawInadequate
effective: Staff support: induction, training, skills and experienceInadequate
St Elizabeth's Domiciliary Care Agency improved from its previous Inadequate rating but remains in breach of Regulations 12 and 17, with ongoing failures in medicines management, risk assessment documentation, and governance oversight. The service was removed from Special Measures following demonstrated improvements, though further development is required to sustain safe and well-led care.
Concerns (6)
criticalMedication management: “medicines were not always stored at the correct temperatures. Records of temperature monitoring was inconsistent and in one bungalow the intervention medicines were being stored in a room with a temperature reading of 30⁰C.”
criticalCare planning: “People's risk assessments were not always clear or coordinated with the information stated in the care plans. There were examples where risks had been identified but risk management strategies were not clear.”
criticalGovernance: “actions following the audits were not always captured in a service improvement plan, which meant the management team did not have clear oversight that these actions were being completed.”
moderateMedication management: “There were no records of why certain 'when required' (PRN) medicines had been administered or if they had been effective.”
moderateConsent / capacity: “Where people lacked capacity to make a decision, we found not all decisions were documented in a way that assured us that the person's voice was heard.”
minorPerson-centred care: “Staff using language that was not always respectful or encouraged equality. For example, people being 'Non-compliant' and 'Staff toilets'.”
Strengths
· Staff adhered to safe practices when wearing personal protective equipment (PPE).
· Sufficient staffing levels in place at time of inspection with additional management personnel added to drive improvement.
· Improved incident and accident management with senior management reviewing and sharing lessons learnt.
· Safe recruitment process with DBS checks and satisfactory references obtained for all staff.
· Staff able to recognise signs of abuse and felt comfortable raising safeguarding concerns with management.
St Elizabeth's Domiciliary Care Agency remained rated Inadequate across safe, effective and well-led at this focused re-inspection, with continued regulatory breaches of Regulations 9, 12, 17 and 18, including critically low staffing, unsafe medicines management affecting only 25% trained staff, and a failure to act on lessons from the previous inspection. The service remained in Special Measures with no registered manager in post and no meaningful improvement since the February 2022 inspection.
Concerns (14)
criticalMedication management: “Only 26% of staff were trained to administer emergency intervention medicines and 25% of staff to administer medicines.”
criticalMedication management: “documents to help staff to administer when required 'PRN' medicines were not in place for all prescribed medicines.”
criticalStaffing levels: “there had been times where staffing levels were critically low which put people at risk... people had not received their commissioned hours.”
criticalStaff training: “only 24% of staff had received this [first aid training]. Only 25% of staff were medicine trained.”
criticalIncident learning: “There was a lack of shared lessons learnt with the whole team... the manager did not effectively look at the overall trends and themes.”
criticalGovernance: “provider had shown an inability to effectively and in a timely way address the concerns raised at the previous inspection.”
criticalSafeguarding: “Staff were not always confident on what to look out for or recognise where people were put at risk of abuse.”
moderateCare planning: “People's risk assessments were not clear or coordinated with the information stated in the care plans.”
moderatePerson-centred care: “Care and support plans failed to reflect people's aspirations and future goals or focus on people's quality of life outcomes.”
moderateConsent / capacity: “Staff were not always able to explain why there were decisions to restrict people or if this was the least restrictive measure to take.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post.”
moderateRecord keeping: “Records were sometimes being completed by staff not employed by the provider.”
moderateCultural competency: “Staff used language that was not respectful or age appropriate for example, using language such as 'good boy' and being 'non-compliant.'”
minorCommunication with families: “One relative said, 'They are lovely people, but they just keep changing - we don't know what they are doing.'”
Strengths
· The provider operated a safe recruitment process with DBS checks and satisfactory references obtained for all staff before working with people.
· Sufficient PPE was available and staff were observed wearing it correctly during inspection.
· People felt staff were kind and felt happy with the support; people said they felt safe.
· The provider engaged with external professionals following the previous inspection to help improve support.
· The provider had been open and honest about the inspection, offering meetings to discuss findings with staff, residents and families.
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Preventing and controlling infectionRequires improvement
effective: Assessing people's needs and choices; person-centred careInadequate
effective: Staff support: induction, training, skills and experienceInadequate
effective: Supporting people to eat and drink; access healthcareRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
St Elizabeth's Domiciliary Care Agency received a 'Good' rating across all five key questions at its September 2019 inspection, reflecting strong person-centred practice, effective safeguarding systems, skilled and well-supported staff, and consistent, high-quality leadership. No areas of concern or regulatory breaches were identified during the inspection.
Strengths
· People felt safe and were protected from avoidable harm; safeguarding concerns were reported and investigated appropriately with learning shared across staff.
· Robust recruitment processes and consistent staffing arrangements minimised agency staff use, ensuring continuity of care.
· Staff were well trained, knowledgeable about individuals' needs, and competency-checked for medication administration.
· Person-centred care plans developed in partnership with people, reflecting their life history, preferences, and goals for independence.
· People were supported to access healthcare professionals, with health action plans in place and effective multi-agency working.
effective: Ensuring consent to care and treatment in line with law and guidanceInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringInadequate
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Continuous learning and improving careInadequate
well-led: Working in partnership with othersRequires improvement
well-led: Promoting a positive, person-centred, open and inclusive cultureInadequate
well-led: Governance, quality performance monitoring and continuous learningInadequate
well-led: Engaging and involving people, staff and duty of candourRequires improvement