Elmar Home Care Ltd – Horsforth received an overall rating of Requires Improvement at its May 2023 focused inspection, retaining this rating for a second consecutive cycle, with a regulatory breach identified under Regulation 19 for unsafe staff recruitment practices. Strengths were noted in medicines management, safeguarding, person-centred care planning, and communication, while governance weaknesses centred on poor incident follow-up and failure to embed lessons learned into practice.
Concerns (6)
criticalStaff competency
: “Evidence of conduct in previous employment, application forms and full employment history were not always in place.”
moderateGovernance: “these systems did not highlight staff recruitment and incident follow up concerns we identified. When things did go wrong, the provider did not routinely use lessons learnt to improve the service.”
moderateIncident learning: “incidents, although fully recorded by staff had not always been followed up or reviewed. This meant we were not assured lessons learned was always effective.”
moderateRecord keeping: “care records did not always record when incidents had been followed up.”
moderateLeadership: “evidence to show how lessons learnt were routinely used to improve the quality of the service, particularly communications to staff were not in place.”
minorCare planning: “Systems and processes were mostly in place to assess people's needs prior to care and support commencing. Outcomes for people were identified and regularly reviewed. However, these were often task focussed.”
Strengths
· Medicines were managed safely with accurate MARs and staff competency assessed
· People felt safe and staff were knowledgeable about safeguarding and abuse prevention
· Care plans were person-centred including pictorial formats and translated languages
· People and relatives were involved in developing care plans with preferences recorded
· Staff supported people to access healthcare professionals and community activities
Quality-Statement breakdown (20)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
responsive: End of life care and supportRequires improvement
responsive: Planning personalised care to ensure people have choice and controlGood
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: Managers and staff being clear about their roles; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires 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