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CQC report explained · a residential care home, run by Elizabeth House Rest Home
Elizabeth House
Sandy Hill, Werrington, Stoke-on-Trent, ST9 0ET
Requires improvementpublished 5 September 2025, 11 months ago
Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.
The latest report, explained
What inspectors found, January 2024
Requires Improvement; inspectors found kind care and enough staff, but environmental safety, infection control and management checks were not effective.
This was an unannounced, focused inspection on 29 November 2023. Inspectors spoke with people, relatives and staff, and checked care, medicine, recruitment and management records. They also looked around the home.
The home was rated Requires Improvement overall, and for Safe and Well-led. Inspectors found problems with cleanliness, maintenance and equipment storage. These included a blocked fire exit, an unlocked boiler room with uncovered hot pipes, and some areas needing deep cleaning.
People and relatives generally spoke positively about the care. Inspectors found enough staff, safe recruitment, safeguarding training and support with medicines, although records for rotating pain-relief patches were not always complete.
The home was rated Good at the previous inspection. Because this inspection only looked at Safe and Well-led, the other ratings were carried over from the previous inspection. The provider said it had already made some repairs, improved cleaning and strengthened its monitoring systems.
What inspectors praised
Enough staff
Inspectors found enough staff on duty, including for people who needed one-to-one support. Relatives said people did not have to wait long.
“There seems enough staff. You do not have to wait. You see the same staff all the time.” from the report
People felt safe
People and relatives said they felt safe and staff knew how to report safeguarding concerns.
“People told us they felt safe living in the home.” from the report
Respect for choices
Inspectors found that staff supported people to make daily choices and worked within the principles of the Mental Capacity Act.
“Staff empowered people to make their own decisions about their care and support.” from the report
Learning from incidents
Accidents and incidents were investigated, discussed with staff and used to look for lessons and trends.
“Incidents were reviewed in team meetings and lessons learnt were shared with the staff team.” from the report
What inspectors were concerned about
Unsafe environment
seriousThe home needed better maintenance and cleaning. Equipment partly blocked a fire exit, and an unlocked boiler room contained uncovered hot pipes.
“Trollies were being stored in a corridor which partially blocked a fire exit.” from the report
Weak infection control
seriousSome areas needed deep cleaning and a shared bathroom was being used to store wheelchairs. Cleaning checks did not reliably identify or correct these problems.
“Some areas of the home required deep cleaning. Staining was evidence on skirting boards, walls, doors, and light switches.” from the report
Medicine records
needs fixingRecords did not show that pain-relief patches were always rotated according to the manufacturer's guidance. The registered manager changed the monitoring system immediately.
“Where people required the administration of pain relief through patches, records did not demonstrate they were being rotated in line with manufacturer guidance.” from the report
Quality checks missed risks
seriousAudits did not reliably identify environmental problems, missing risk assessments, outdated care information or how long people waited for call bells to be answered.
“Quality monitoring processes had not always ensured risks to people were being identified and mitigated.” from the report
Questions to ask them, based on this report
- 01What repairs, redecoration and deep cleaning have been completed since the inspection, and how are you checking that standards stay high?
- 02How are fire exits kept clear and how is access to the boiler room controlled?
- 03How do you now check that pain-relief patches are rotated correctly and recorded?
- 04How do you monitor call-bell waiting times and respond if people wait too long?
- 05Who is responsible for the home when the registered manager is working at the other service, and how is this oversight checked?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 19 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
The story over the years
Every inspection of Elizabeth House
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Goodstayed GoodSafe: GoodWell-led: Good
- April 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- November 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 9 March 2011.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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