CQC report explained · a residential care home
What the CQC found at 207 Goodmayes Lane
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People said they felt safe and there were enough staff. However, financial safeguards and some risk assessments were not adequate, including missing emergency evacuation plans and gaps in food temperature checks.
- Effective?
- Requires improvement
- Staff received training, people had access to healthcare and were supported with food and drink. Staff supervision was not consistently recorded, and assessments did not cover equality and diversity needs.
- Caring?
- Good
- People told inspectors that staff were kind, respectful and caring. People were involved in decisions, had privacy, and were supported to maintain their independence and relationships.
- Responsive?
- Requires improvement
- People had person-centred plans for several areas, and were supported with communication, activities and visitors. Plans did not comprehensively cover equality and diversity or end of life care.
- Well-led?
- Requires improvement
- There was an open culture, staff knew their roles and the provider worked with other agencies. However, quality checks had failed to identify important gaps in risk assessments, care plans and monitoring of people's money.
What inspectors found, March 2023
Requires Improvement; inspectors found kind care and enough staff, but important safety, care planning and management systems were still not reliable.
This was a follow-up inspection after an earlier inspection in May 2022. Inspectors visited on 12 January 2023, spoke with one person and three staff, observed care, and checked care, medicine, recruitment and management records.
People said they felt safe, staff were kind, and there were enough staff. Medicines were managed safely overall, recruitment checks had improved, the home was clean and homely, and people were supported with food, healthcare, activities and relationships.
However, inspectors found gaps in risk assessments, financial safeguards, care plans and quality checks. Care plans did not cover equality and diversity needs or end of life care. The home was still in breach of four regulations. The overall rating was Requires Improvement, although caring was rated Good.
Kind and respectful staff
People described staff as kind and respectful. Inspectors saw friendly interactions and people appeared relaxed with staff.
“People were treated well. People told us they liked the staff and got on well with them.” from the report
Choice and independence
People were involved in decisions about their care, food and clothing. Staff respected privacy and supported independence.
“People were supported to express their views and be involved in making decisions about their care.” from the report
Activities and relationships
People could see visitors and take part in activities such as places of worship, tea dances, parks and cafes.
“The service supported people to engage in various activities.” from the report
Staffing and recruitment improved
Inspectors found enough staff at the time of the visit, and recruitment checks that had been missing previously were now in place.
“There were enough staff working at the service.” from the report
Medicines managed safely overall
Medicines were stored securely, records were accurate and staff had training. Inspectors did recommend further work on controlled drugs.
“Medicine administration records were kept. These were accurate and up to date.” from the report
Financial safeguards
seriousMoney belonging to people was paid into the provider's business account without full receipts, auditing or records of spending. Inspectors found no evidence that anyone had been harmed, but said this created a risk of financial abuse.
“The provider did not have adequate systems to protect people from the risk of financial abuse.” from the report
Incomplete risk planning
seriousSome risks had not been assessed properly. People did not have individual emergency evacuation plans, and fridge and freezer temperatures had not been checked since July 2022.
“People did not have Personal Emergency Evacuation Plans (PEEPs)in place.” from the report
Care plans missed important needs
seriousCare plans did not cover equality and diversity needs or end of life care. The provider said these plans would be added.
“However, there were no care plans in place around people's needs related to equality and diversity needs.” from the report
Quality checks were not effective
seriousThe provider had audits and reviews, but they had not identified the gaps in risk assessments, care plans or money monitoring. The home was still in breach of the good governance regulation.
“Quality assurance and monitoring systems were in place, but these were not always effective.” from the report
Supervision records
minorStaff supervision was sometimes carried out verbally but was not recorded consistently. Inspectors recommended a clear policy for regular recorded supervision.
“These were not written down, they were oral.” from the report
- 01What has been done to keep people's money separate from the provider's business account and to record every expense with receipts?
- 02Have individual Personal Emergency Evacuation Plans now been completed for everyone who needs one?
- 03How have care plans been updated to cover equality and diversity needs and end of life care?
- 04How are you now checking that risk assessments, care plans and financial records are complete and accurate?
- 05How often is staff supervision carried out, and where are the written records?
This was a follow-up inspection that assessed all five key questions, with Safe and Well-led following up earlier Inadequate ratings; Effective, Caring and Responsive received their first ratings for this newly registered service. This explanation was written from the published report of 8 March 2023 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.
What inspectors found, June 2022
Safe and well-led were rated Inadequate; the overall service was not rated because inspectors found insufficient evidence.
This was the first inspection since the home registered. It began as a targeted check of infection control and COVID-19 vaccination arrangements. Inspectors widened it to a focused inspection after finding concerns about the premises and records.
Inspectors found serious problems with medicines, risk assessments, incident records, staff recruitment and safeguarding. Medicines were not always stored securely, records had gaps, and staff had not been shown to be trained or checked as safe to work with people.
The home was also poorly managed. Records were incomplete or inaccurate, quality checks were not reliable, and the provider could not show clear evidence of staff induction, training, supervision or meetings. Infection control arrangements were in place, and there were enough staff to support the two people living there.
The provider sent some information after the inspection, including evidence of some DBS checks, locked COSHH cupboards and a training provider. The report says warning notices were issued and that the CQC would monitor progress with the provider and local authority.
Infection control
Visitors were offered PPE, temperatures and COVID-19 status were checked, and staff testing records were in order. The premises appeared clean, although the office outhouse smelled damp.
“There were systems in place to prevent visitors from catching and spreading infections.” from the report
Staff cover
Inspectors found enough staff to support the two people living at the home. The provider and manager said they could provide cover if there was an emergency staff shortage.
“There were enough staff working to support people.” from the report
Medicines were not safely managed
seriousMedicines were stored in unlocked cupboards and administration records had gaps. There was no evidence that staff had been trained or checked as competent to give medicines.
“We found no evidence staff had been trained to administer medicines or had been competency assessed to do so.” from the report
Risks were not fully assessed
seriousCare records did not always explain people's health risks or what staff should do to reduce them. Some risk assessments included generic and inaccurate information about controls that were not in place.
“Risks to people were not always recorded nor was information on how to mitigate those risks.” from the report
Recruitment checks were incomplete
seriousReferences were not properly recorded and two staff DBS checks were completed only after the inspection. This meant the provider had not assured itself that staff were suitable to work with people.
“Two of the three staff had their DBS checks completed following the inspection as they had not been checked before we attended the service.” from the report
Safeguarding training was missing
seriousStaff had not been trained to recognise abuse. The manager also did not know the local safeguarding process for raising concerns.
“The provider had not ensured staff had been trained in safeguarding or how to identify abuse.” from the report
Training evidence was inadequate
needs fixingThe provider could not clearly show that staff had received induction, training or recorded supervision. Staff had not been taught a consistent approach to medicines, safeguarding, infection control or basic life support.
“The provider was unable to clearly evidence staff had received an induction or training.” from the report
Poor management and records
seriousCare plans, staff files and quality audits were incomplete or inaccurate. The home did not have reliable systems to check care quality or learn from incidents.
“There were numerous shortfalls in the governance of this service.” from the report
- 01How are medicines now stored securely, recorded on MAR sheets and checked through regular audits?
- 02What evidence can you show that every staff member has completed safeguarding, medicines, infection control and basic life support training?
- 03Have all staff recruitment files been completed with satisfactory references and DBS checks before staff work with people?
- 04How are risks linked to each person's serious health conditions recorded, monitored and explained to staff?
- 05What quality checks, incident reviews and staff or resident meetings are now taking place, and can we see the records?
This began as a targeted infection control inspection and was expanded to a focused inspection of Safe and Well-led; Effective was not fully reviewed, and Caring and Responsive were not rated. This explanation was written from the published report of 28 June 2022 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.
Every inspection of 207 Goodmayes Lane
Each visit the CQC has published, newest first, back to the day the home was registered.
- March 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2022Insufficient evidence to rateSafe: InadequateEffective: Insufficient evidence to rateWell-led: Inadequate
- March 2021
Registered with the Care Quality Commission on 18 March 2021.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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At least 100 live-in carers within about an hour of Redbridge
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,250 a week. 75 can care for a couple. 10 years' experience on average.
“Sidonia is a first class live-in carer whose dedication and thoughtfulness made her stay a happy experience.”
“Charity would take Nan on holidays day trips and shopping adventures”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.