Elmes Homecare

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe and we were not fully assured about safety.

We found the provider to be in breach of 3 legal regulations relating to safe care and treatment, staffing and recruitment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Records showed there had been an incident in relation to medicines, in March 2025. The incident involved 2 doses of a medicine being administered to a person instead of 1. This error had not been logged on the accident and accidents log and no follow up actions were recorded.

There was a system in place to report and investigate medicines-related incidents, however, we found it had not been applied to medicine incidents and learning was not shared with staff to ensure that similar incidents could not occur in the future. Although we saw that the incident of double dosing in March 2025 had been investigated as a safeguarding, the incident had not been reported as a medicines-related incident and no updated guidance for staff had been put in place to mitigate a reoccurrence.

There had had been 16 incidents logged since the last inspection in 2021; however, records did not document any lessons learnt from these incidents. For example, one incident involved a person sustaining as a minor injury with a hoist in the presence of a staff member. The incident log documented that the staff member was required to undertake a refresher in moving and handling training and that spot checks and supervision would take place. However, there were no records to show that the provider had taken these actions, lessons learnt and how this was shared with all staff.

We raised this with registered manager and director, who told us accidents and incidents were discussed during manager meetings and discussed with care staff on an individual basis, however, these were not documented. Records also showed accident and incidents had not been analysed to identify potential lessons learnt that could be shared with all staff to help embed good practice. Accidents and incidents audits were not effective as they did not identify that follow up actions were not documented and that learning was not shared with all staff.

Systems were in place to ensure continuity of care. Assessments of people’s needs were carried out prior to joining the service to ensure their care needs could be met. Assessments were also carried out if people had been in hospital and were returning home, this ensured effective transition from hospital to people’s home. Care plans showed the involvement of health care professionals such as GPs and district nurses.

We asked relatives if their family member felt safe using the service. Their responses included, “[My family member] is very safe” and [My family member] feels safe [with staff].”

There were safeguarding, whistleblowing and duty of candour policies in place. Staff we spoke with understood their responsibilities in relation to safeguarding. They had completed safeguarding training and were able to demonstrate knowledge of different types of abuse and reporting procedures if they had any concerns of abuse.

However, the provider did not always recognise their duty to raise safeguarding concerns with relevant agencies. We found 2 concerns of potential abuse. Not all concerns of abuse had been reported to the local authority and the provider had failed to inform CQC of the safeguarding concerns.

Risks to people’s health and wellbeing had either not been assessed or if they had the measures put in place to mitigate the risk were not adequate. For example, there were not always person-centred risk assessments or risk management plans in place for people in relation to Parkinson’s disease; strokes, multiple sclerosis, dementia, seizures, falls, skin integrity and dysphagia (dysphagia is a medical term for difficulty swallowing and a risk of choking). We reviewed 8 care records, these showed two people had Parkinson’s disease, and that their condition impacted their mobility. However, neither person’s mobility risk assessments documented how their mobility was impacted, what the risks were and how to mitigate any potential risks

Another person at risk of dysphagia had contradictory information in their care plan, which stated they were ‘able to swallow safely’. However, there had been input from a speech and language therapist (SALT), stating that the person’s food should be pureed, have slightly thickened fluids and support with eating meals was required. Under ‘risks and mitigation’, choking was listed as a risk for this individual; the mitigation was recorded as, ‘carers to ensure they are following guidance provided by speech and language. As well as care plan’. However, records showed that under the SALT guidance, the provider had recorded that ‘no risks have been identified’. There were no other details of the potential risks that could lead to a choking incident or the actions staff should take to mitigate the risk of choking such as ensuring that there was no food left in the person’s mouth before offering more food, or ensuring they were offered a drink at regular intervals. There was also no guidance on what staff should do, if the person choked.

We spoke with staff, one staff member told us, “There is not a specific Parkinson’s risk assessment, I just use common sense.” Another staff member said, “There are no Parkinsons, strokes, or dysphagia risk assessments.”

Some people used mobility aids, such as standing frames, hoists or shower chairs. However, their moving and handling, and falls risk assessments did not always identify the potential risks of using these mobility aids. There was not always guidance in place for staff on how to safely mobilise the person and how to minimise potential risks. For example, one person who had slipped from a shower chair, did not have a falls risk assessment or a risk management plan in place outlining the potential risks in using the shower chair and how to mitigate these risks safely or what to do should the person have a fall.

There was contradictory information detailed in another’s person’s mobility risk assessment, who was not mobile and fully dependent on staff to support them to mobilise using a mobility aid. However, the risk assessment stated that they were able to independently mobilise using a mobility aid. The mobility risk assessment had not been updated when their needs changed to being fully dependent on staff to mobilise. There was no falls risk assessment and no risk management in place to guide staff on how to safely mitigate the risk of falls or what to do should the person have a fall. Another person had two falls within 3 months, their care plan after each incident stated ‘risk assess and check and monitor for falls’. However, there were no records showing that these risks had been reassessed and updated after each fall. This meant people’s care plan and risk assessments were not always updated following an accident or incident to reflect changes in their care needs.

We raised these issues with the provider who immediately put an up-to-date risk management plan in place for the person who slipped from the shower chair. The provider assured us that suitable risk assessments and management plans would be put in place for all people at risk of falls as soon as possible to maintain their safety.

People told us they were supported to keep safe in their home environment by ensuring there were no hazards. Environmental risk assessments had been carried out of people’s homes and included stair, stairlifts, fire safety, smoking and pets.

Recruitment processes were not robust and were not consistently implemented. People were at risk of receiving care from staff that had not been proven to be of good character before they were employed. We reviewed 9 staff files and saw Disclosure and Barring Service (DBS) checks were not always carried out for all staff before they were employed. DBS checks ensure staff do not have any criminal convictions and were suitable to provide support for people. We saw DBS checks carried out by previous employers were accepted by the provider for 3 staff members.

We raised this issue with the registered manager and director who told us, it was their understanding that they could accept a DBS from a previous employer if it was dated within the last 6 months of them commencing employment with the service. However, providers must be able to demonstrate sound reasons for not obtaining a full DBS check before a staff member was employed and also demonstrate any potential risk had been assessed. For all 3 staff members, there were no reasons recorded as to why a full DBS check was not obtained by the provider and potential risks were not assessed.

The staff files we reviewed showed that the provider had failed to ensure that two adequate references (one of which must be from the most recent employer) were obtained before staff commenced work. The provider’s policy stated, “Individuals will not be allowed to commence work before Elmes Homecare Limited has received responses to its requests for references’. However, we found one staff member had commenced employment on the day that their 1st reference was received, the 2nd reference was not received until 2 weeks after they had started work. For another staff member, only 1 reference was received before they started work, but the 2nd reference was not received until 1 week after they started work. This second reference was also not completed in full and only included dates of employment.

We also saw that recruitment records were not always fully completed, application forms for 4 staff members did not record the roles applied for. Interview forms for 6 staff members showed scoring had not been completed which assessed and confirmed their suitability and competency for the roles applied for.

The service used a number of methods to assess the competency of staff such as competency and spot checks, however some were not fully completed, and areas of improvement had not been followed up. Therefore, we could not be assured how effective the assessments were in establishing the competency of staff. For example, medicines competency tests for 6 staff had not been scored to assess and confirm satisfactory knowledge and competence of staff. One competency check completed for a staff member stated they had not washed their hands and a moving and handling issue had also been identified. There were no follow up actions to show how improvements would be driven. The competency check had also not been signed by either the assessor or staff member.

Staff file checklists and audits were completed; however, they were not robust as they failed to identify the issues in relation to DBS checks, interview record keeping and competency assessments we found at this assessment.

Records showed that staff had received training in areas such as infection control, safeguarding, mental capacity, medicines, moving and handling, fire safety, diversity and equality, diabetes, dementia, first aid, infection control and food hygiene. However, 1 care record we reviewed, showed that the person had dysphagia and was at risk of choking., There was no specific training in relation to dysphagia or choking to ensure staff fully understood how these conditions impacted people as individuals. Staff did complete first aid training and there was general written information on dysphagia and a dysphagia and choking risk policy in place. However, this was generic information and not specific to people’s individual needs.

2 people’s care records showed they had Parkinsons disease and 1 person had experienced a stroke, however staff had not received training in relation to Parkinson’s disease and stroke management. When speaking to staff, they told us they had not received this specific training. Staff comments included, “No specific Parkinsons training or dysphagia training, choking was touched on in first aid training”, “I have not had internal training given on Parkinsons. Not had specific dysphagia or choking training. It would be beneficial”, “No specific dysphagia, Parkinsons and strokes [training]”, and “Not had specific dysphagia/choking training. I know people need to eat slowly and have a drink.”

At the time of the inspection, staff had not received learning disability autism training, but subsequently, the provider took steps to ensure staff receive this training.

People and relatives told us there were enough staff to meet people’s needs. Overall staff were on time, they never missed a care visit and called people or their relatives if they were going to be late. Staff stayed for the duration of the care call and people never felt rushed. Relatives we spoke with told us,” [Staff] are always on time and never leave early” and “[Staff] are not always dead-on time but give or take 15 minutes is fine-they do ring me though if it is going to be any later-never miss a call”

The provider had an electronic call monitoring system which could accurately reflect the times staff attended care calls and ensured staff were effectively deployed to attend people’s calls in a timely manner.

Staff told us there were sufficient staffing numbers to safely meet people’s needs. However, we received mixed feedback about the travel time they had between calls. Some staff told us they had enough travel time and others told us they did not.

People and their relatives did not have any concerns about infection control and prevention. People’s relatives confirmed staff wore appropriate personal protective equipment (PPE) when delivering personal care.

There were infection control policies and procedures in place and staff received training in infection prevention and control and had access to sufficient supplies of PPE. We saw regular PPE audits were carried out and no issues were identified.

Medicines were not always safely managed. Medicine Administration Records (MARs) showed some unexplained, omitted doses. Risks were not always appropriately assessed when relatives were administering people’s medicines. One staff member we spoke with told us, “Sometimes medicine is given by family members, this can be due to us being late for calls and it is past their medicine time, or sometimes family just give medicines before we get there,” Another staff member said, “Family do sometimes give medicines when we are late.” A third staff member said, “Some families do give medicines, and we mark the MAR as not observed.”

Some medicines were administered by family members and not staff when people were not scheduled to have a care call. However, the provider did not keep records of these medicines. By not retaining a list of all medicines people were taking had posed a risk as they did not have information about potential side-effects to look out for from medicines that staff did not administer.

MAR records were not always robust as they did not always record all medicines people were taking and did not record people’s PRN (as and when needed) medicines. We identified some gaps on MAR records that had not been accounted for and were recorded with a question mark. The provider could therefore not be assured if medicines were administered as prescribed.

Medicine risks management plans did not always document actions staff needed to take should people become unwell or guidance on how certain medicine devices should be used. For example, what to do if people experienced side effects medicines or how to appropriately use an inhaler.

We saw that there was an up-to-date medicines policy in place. Records showed that staff had received training on the administration of medicines and their competency to administer medicines had been assessed and medicines were safely stored.