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Archived: ELMS in Waltham Forest Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

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.

Inspection areas


Requires improvement

Updated 28 March 2018

The service was not consistently safe. Although risk assessments were carried out they did not provide details on how risks should be managed. They did not include triggers for staff to observe to identify people who may be suffering a relapse. Medicine administration records were not always up to date.

People were protected from the risk of abuse because staff knew what to do should they suspect abuse.

Staff were subjected to the necessary checks before starting work, however, we found gaps in references for staff. We found the deployment of staff and staff training were not sufficient.



Updated 28 March 2018

The service was effective. Staff received training in most areas, however, there were gaps in specialist training such as diabetes and behaviours that challenged the service.

The service met the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

Staff understood the importance of asking people for their consent before supporting them.

People had access to food and drink of their choice and were involved in shopping for the home.



Updated 28 March 2018

The service was caring. People were treated with dignity and respect.

People were encouraged to maintain positive relationships. They received visits from family members and friends were encouraged.

People had access to advocates and their human rights were protected.



Updated 28 March 2018

The service was responsive. People received personalised care tailored to their needs. Care plans documented people�s histories and information on how to support them However, these were not always written in a person-centred manner.

People were able to make a complaint knowing that staff would act on these in a timely manner.


Requires improvement

Updated 28 March 2018

The service was not consistently well-led. Systems to monitor the quality of the service were not effective. The registered manager had not identified issues found by us during our inspection.

People and staff spoke highly of the registered manager and other staff. They felt able to approach staff with any concerns knowing this would be acted upon.