207 Goodmayes Lane was rated Requires Improvement overall at this January 2023 inspection, with four regulatory breaches identified covering safeguarding from financial abuse (Reg 13), risk assessment (Reg 12), person-centred care planning (Reg 9), and governance (Reg 17). Caring was rated Good, reflecting staff who treated people with kindness and respect, though significant gaps in care plans, quality assurance, and financial oversight controls remained unresolved since the previous inspection.
Concerns (7)
criticalSafeguarding: “The provider did not have adequate systems to protect people from the risk of financial abuse. Money belonging to people was paid directly into the provider's business account.”
criticalCare planning: “There were no care plans in place around people's needs related to equality and diversity needs. There were no care plans in place around end of life care for people.”
criticalGovernance: “Quality assurance and monitoring systems were in place, but these were not always effective... had failed to identify that risk assessments did not cover all significant risks.”
criticalRecord keeping: “The provider had failed to implement robust systems to protect people from the risk of financial abuse... no auditing or recording of how much money was spent on behalf of people.”
moderateSupervision / appraisal: “A director told us they had regular one to one supervision with staff but that this was not always recorded, saying, 'These were not written down, they were oral.'”
moderatePerson-centred care: “People did not have Personal Emergency Evacuation Plans (PEEPs) in place... The nominated individual told us they did not know this was required.”
minorMedication management: “Staff did not fully understand the legal requirements for the management of controlled drugs.”
Strengths
· Medicines were managed safely with accurate and up-to-date administration records and secure storage.
· Staff recruitment practices were improved with DBS checks, references and proof of identity in place.
· Infection prevention and control measures were effective and assured.
· People were treated with kindness, dignity and respect and felt happy at the service.
· Accidents and incidents were now reviewed to learn lessons and prevent recurrence.
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control; End of life care and supportRequires improvement
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships; support to follow interests and activitiesGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Continuous learning and improving care; Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
safe:Inadequateeffective:Insufficient evidence to ratewell-led:Inadequate
First inspection of a newly registered six-bed care home found widespread failings in medicines management, risk assessment, recruitment, safeguarding training and governance, leading to breaches of Regulations 12, 13, 17 and 19 and warning notices issued to the provider and registered manager. Safe and well-led were rated Inadequate while effective had insufficient evidence to rate; only infection prevention and control measures were satisfactory.
Concerns (12)
criticalMedication management: “we found gaps on people's Medicines Administration Record (MAR) sheets”
criticalMedication management: “We saw medicines were being stored in unlocked cupboards... When we returned for the second day, they remained unlocked.”
criticalStaff training: “We found no evidence staff had been trained to administer medicines or had been competency assessed to do so.”
criticalSafeguarding: “People were not safeguarded from the risk of abuse. The provider had not ensured staff had been trained in safeguarding or how to identify abuse.”
criticalStaff competency: “Staff recruitment measures were not robust... Two of the three staff had their DBS checks completed following the inspection”
criticalCare planning: “Risks to people were not always recorded nor was information on how to mitigate those risks.”
criticalGovernance: “There were numerous shortfalls in the governance of this service... Governance at the service was lacking. The service did not have adequate quality assurance in place.”
criticalRecord keeping: “the provider had failed to maintain accurate records in relation to the management of regulated activity”
criticalLeadership: “The management of this care home was inadequate... they exhibited a lack of understanding of what was required to manage a care home.”
moderateIncident learning: “Lessons were not always learned when things went wrong. Incidents and accidents were not always recorded as such.”
moderateSupervision / appraisal: “The registered manager told us they had not provided supervision to staff. The provider told us they had given supervision but had not recorded it.”
minorCommunication with families: “The provider told us they held meetings with staff and people but told us none of these were recorded”
Strengths
· There were systems in place to prevent visitors from catching and spreading infections; PPE offered, temperatures checked and COVID-19 status sought.
· Sufficient PPE available and premises appeared clean throughout.
· Service was meeting the current requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.
· There were enough staff working to support people; rotas confirmed this.
· One person was positive about management, saying 'They are fine [management]. I can't complain.'
Quality-Statement breakdown (10)
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongInadequate
safe: Staffing and recruitmentInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceInsufficient evidence to rate
well-led: Promoting a positive culture; managers and staff being clear about their rolesInadequate
well-led: Continuous learning and improving care
Inadequate
well-led: Engaging and involving people using the service, the public and staffInadequate
well-led: Working in partnership with othersInadequate