Archived: ELMS in Waltham Forest

Updated 28 March 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 20 and 23 October, and was unannounced on the first day.

The inspection team consisted of an adult social care inspector.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We gathered information and intelligence we held about the service, this includes notifications submitted by the provider. Notifications are changes or events that occur at the service which the provider has a legal duty to inform us about.

During our inspection we spoke with three people using the service and three staff members, including the registered manager. We reviewed various records, including three care records for people using the service, such as care plans, risk assessments and medicines administration records. We looked at various policies and procedures including equalities and diversity, complaints and suggestions and accident and incident reporting. We also reviewed documentation requested and sent in by the provider. This included additional policies such as safeguarding and protection, induction and training and medication. We were also sent a copy of the staff training matrix, group supervision records and minutes of staff meetings.

Updated 28 March 2018

The inspection took place on 20 and 23 October 2017, the first day of inspection was unannounced. At our last inspection on 8 October 2015 we found the provider was in breach of Regulation 12 safe care and treatment. At this inspection we found some improvements had been made, but further improvements were required to ensure that risk assessments were more comprehensive and detailed actions for how risks would be mitigated.

ELMS in Waltham Forest is a three bedded care home. The home specialises in providing support for people with mental health conditions and working towards them developing their independence. There were three people using the service at the time of our inspection. Each person had their own room and shared communal areas such as bathroom, lounge, kitchen and the garden.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines were stored safely, however we found gaps in medicine administration records.

People were protected from the risk of abuse because staff knew what to do and how to report any suspicions to their manager and the relevant authority.

The service operated within the legal framework of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Risk assessments identified areas of risks, however they did not include guidance for staff on how these risks should be mitigated.

The registered manager told us that staffing levels were sufficient to meet people’s needs. We found staff were not deployed appropriately to ensure that people were safe.

Staff recruitment procedures were in place, however we found gaps in records relating to staff references and disclosure and barring checks.

Care plans were detailed and provided staff with guidance on how to support people. People received support in line with their plan of care. However, care plans were not written in a person-centred manner.

Staff felt supported by the registered manager and felt able to approach them at any time with their concerns. Some staff had not completed training in specialist areas such as diabetes.

Systems in place to audit the service were not effective as they had not identified the gaps we found on the day of our inspection.

We made recommendations in relation to care plans, staff deployment and staff training.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment, staff recruitment and governance. You can see what action we told the provider to take at the back of the full version of the report.