Elsah Healthcare's first inspection rated the service Requires Improvement overall, with breaches of Regulations 17 (good governance) and 18 (staffing) due to late/short calls, inadequate travel time and weak quality assurance oversight. Effective, caring and responsive domains were rated Good, with positive feedback on staff kindness, training, person-centred care plans and partnership working.
Concerns (10)
critical
Missed or late visits
: “one person's care plan showed their scheduled visit was from 8.00pm for 30 minutes, but they were visited at 9.46pm that was one hour 46 minutes late”
criticalStaffing levels: “Staff were not effectively deployed at all times to support people... some staff calls were not always scheduled as agreed with people.”
criticalCare planning: “one person's care plan showed their scheduled visit was from 9.00am for one hour, however they were visited for nine minutes”
criticalGovernance: “The provider's quality assurance systems were not robust. The provider was not effectively monitoring people's calls to ensure that these were taking place as planned.”
moderateMedication management: “staff recorded in the care log that they administered medicines but the MAR chart was blank for a night's medicine on one day”
moderateRecord keeping: “There was no communication record to show that the office staff had informed people when staff were running late to their scheduled home visits.”
moderateLeadership: “The registered manager did not have an effective oversight of the service. The quality assurance system and processes had failed to identify and correct issues”
moderateIncident learning: “two medicines related incidents were picked up and notified to CQC but not recorded on the June 2021 checks.”
minorStaff training: “a member of staff was not aware about the procedure for reporting any wrongdoing internally to their line manager or to relevant external organizations in line with the whistle-blowing”
minorConsent / capacity: “Staff had received MCA training however a member of staff we spoke with did not understood people's rights under this legislation.”
Strengths
· People and relatives gave positive feedback about safety and being treated well by staff
· Satisfactory background checks (DBS, references, employment history) carried out before staff started work
· People protected from infection risk; staff used PPE correctly and had adequate stock
· Comprehensive induction, shadowing and mandatory training programme for staff
· Person-centred care plans including ethnicity, faith, culture, and social history
Quality-Statement breakdown (22)
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Planning and promoting person-centred, high-quality care and support with openness; and duty of candourNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated