Background to this inspection
Updated
26 July 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
Inspection team
The inspection was carried out by 1 inspector, a regulatory officer and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because we needed to be sure that the provider or registered manager would be in the office to support the inspection.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We spoke with 6 people and 6 relatives about their experience of care. We spoke with 7 staff including the registered manager, human resources manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records. This included 8 people's care records and multiple medication records. A variety of records relating to the governance of the service, including quality assurance audits, policies and procedures were reviewed.
We looked at 6 staff files in relation to recruitment and reviewed supervision and appraisal data. We reviewed feedback from professionals involved with the service. We continued to seek clarification from the provider to validate evidence found following the inspection.
Updated
26 July 2023
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
About the service
Elmar Home Care Limited – Horsforth is a domiciliary care service providing care and support to people in their own homes. The service was providing personal care to 63 people at the time of the inspection.
People’s experience of using this service and what we found
Right Support:
People’s risks were assessed, and their care plans developed in a person-centred way. However, care records did not always record when incidents had been followed up. People told us they received support in line with their assessed needs. People consistently told us their choices were promoted and respected by staff.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Right Care:
Staff had completed the necessary training to meet people's needs and knew how to protect them from abuse and avoidable harm. Medicines were managed safely. Most people and relatives told us that they were involved in the development of their care plans and staff knew how to protect their privacy and dignity. There were good examples how people’s human rights were being protected through person-centred care plans, for example the provider used pictorial care plans and care plans in other languages as appropriate.
Right Culture:
The culture of the service supported people and staff in an inclusive way; enabling people to live their day-to-day lives as they chose to. The provider had quality assurance systems to regularly assess and monitor the service. However, 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. The management team were proactive in addressing our feedback in relation to concerns identified during the inspection.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 28 January 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections.
Why we inspected
We received concerns in relation to the governance of the service. As a result, we undertook a focused inspection to review the key questions of safe effective, responsive and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has remained requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe, and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Elmar Homecare Limited - Horsforth on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified 1 breach in relation to safe recruitment at this inspection. We have made a recommendation about lessons learnt when things go wrong.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.