Queen Elizabeth Care Centre

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to how the service was managed. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The registered manager had supported the service to make and sustain improvements and to develop a positive culture. They told us, “I want staff to have the passion for caring. I want them to see we are all equal and no matter what condition residents have they should have the same quality of life. I want my staff to be confident in their decisions. I want them to be honest and have an open culture.” To achieve these outcomes the registered manager aimed to continually develop staff skills and confidence in their abilities. This was done by implementing training provided both online, externally and internally, through skills sharing and staff acting as champions. Staff we spoke with were positive about the culture within the service and the impact the registered manager had had on the staff team. One staff member told us, “Everything is different now with [manager] here. We do everything correctly now.” Another staff member told us, “I love my job, I love caring for people and [manager] and the nurses always help so we get things right for them [residents].”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. We received consistently positive feedback in relation to the registered manager, deputy manager and nursing team. However, some staff and partner organisations told us it could be difficult to work with the wider provider management team. They told that whilst this could be uncomfortable at times, the registered manager was skilled at intervening and taking the lead in conversations and interventions where required. Staff told us they felt valued, respected and listened to. One staff member told us, “[Manager] has energy and will say thank you. It makes me want to do well for [them].” A second staff member told us, “We can go to [nurses] or [deputy] and ask anything if the manager isn’t here. They are really helpful, and everyone is nice.” Partner organisations told us they had confidence in the registered manager and the team they had built. One professional told us, “[Manager] has really turned the service around and I trust her judgement. It’s nice to go there and see the changes.” The registered manager told us they supported the service wherever possible. They told us, “The manager needs to be the role model. Last week I helped the cleaner, the week before I worked in the kitchen. There should never be a divide. I will be there if they need me to make sure my residents get the right care.”

The registered manager fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident in raising concerns and felt action would be taken. One staff member told us, “The management are wonderful. They provide the training that we need. They ask for our feedback, and they listen. If we have any problems, they want to know and they sort it out immediately.” Processes were in place to provide opportunities for people, relatives and staff to speak up. These included staff meetings, supervisions, residents, relatives and staff meeting, surveys and the whistleblowing policy. The registered manager told us they understood the importance of encouraging feedback. They told us, “Feedback is how we learn. I don’t want problems being swept under the carpet. If there are problems we look at what training is needed and how we can approach things to make it better for everyone.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt the service was an inclusive place to work. One staff member told us, “We all work well as a team. There are no problems with discrimination, it’s more like a family.” All staff were required to complete equality and diversity training, and the provider had a policy in place which reflected expectations throughout the service.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. The registered manager had implemented a range of audits to monitor the quality and safety of the support people received. Whilst these checked systems were in place, they did not always identify shortfalls in the quality of the information and system implementation. Examples included the lack of detail found within end of life care plans, capacity assessments some PRN protocols and staff not always having a good knowledge of people’s life histories. The registered manager took a responsive approach when these shortfalls were discussed and provided assurances they would be addressed and audits modified going forward. In other areas such as health and safety, training records, daily medicines management, incident reviews, care records and infection control we found audits were completed in detail and where shortfalls or concerns were identified these were addressed. For example, where training records showed a reduction in compliance this had been addressed with staff who had reviewed and updated their training. The registered manager understood the need to have systems in place to monitor the service and sustain the improvements made. They told us that in addition to completing audits they always spent time each day outside their office to observe practice. They would also review people’s daily care records to ensure they were in line with people’s needs and were completed in a respectful, person-centred way.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The registered manager had built links with health and social care professionals in addition to local places of worship and a school who visited the service regularly. Links with training provided in the Surrey area had enabled staff acting a champions in different areas to gain skills and understanding in their area of expertise. Positive relationships have also been established with the Surrey County Council Quality Assurance Team who supported the team in their improvements.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The registered manager worked in an open and transparent way with staff and partner organisations to continually develop the service. They had a clear action plan in place which included looking to gain external accreditation and continuing to develop a person-centred approach to people’s care. The registered manager told us, “We are always learning. It is important that as a manager I am learning alongside my staff.” The registered manager also had plans to develop new systems in relation to documentation covering the MCA and end of life care. They told us they felt the current recording system in these two areas did not provide enough flexibility. They said, “No service is ever perfect, and things change with new ideas. We will always keep developing. That’s the part of my job I most enjoy.”