Elmes Homecare

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question Good, at this assessment the rating has changed to Requires Improvement. This meant there was a lack of robust oversight of the safety and quality of care.

We found the provider to be in breach of 1 legal regulation relating to governance.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team did not always demonstrate a culture of learning and improvement or show how this was being embedded into the service to ensure people received safe, high-quality care.The provider engaged in regular conversations with people, relatives and staff. However, it was not always clear how their feedback was being used to improve the service provided.

The provider and management team did not always lead effectively. The provider’s processes for monitoring the service and driving improvement was not always effective. We identified areas of concern and breaches of regulations that had not be identified by the provider.

Staff told us they felt supported by the management team. People we spoke with told us they knew the registered manager and felt the service was well run. One relative said, “It’s a very well-run service, very caring and responsive. It feels homely, not so corporate as some services” and “I did my research, that why I picked them”.

The provider promoted equality and equity for the staff who worked for them. Staff were comfortable speaking to the registered manager if they had concerns and could request additional support as required to help them in their role.

Staff told us they were treated equally and they with the registered manager worked well together as a team. Policies and procedures were in place for workforce equality, diversity and inclusion.

The provider promoted equality and equity for the staff who worked for them. Staff were comfortable speaking to the registered manager if they had concerns and could request additional support as required to help them in their role.

Staff told us they were treated equally and they with the registered manager worked well together as a team. Policies and procedures were in place fr workforce equality, diversity and inclusion.

The provider’s monitoring and governance processes were not sufficiently robust. The provider carried out a number of audits. However, these audits which covered risk assessments, risk management plans, medicines management, recruitment records and staff training had failed to identify and resolve the concerns we found at this inspection.

People’s care plans did not include all relevant information about their specific health conditions and how they impacted them as individuals and updates to people’s care needs were not always recorded.

The provider’s systems to identify and manage risks were not always effective, as they had not always identified the risks people faced while receiving care and had not always put effective risk management plans in place to address identified risks.

The systems to ensure people always received their medicines safely were not always effective, as we identified shortfalls with the way the provider was managing people’s medicines, which placed people at risk of unsafe care.

We were also not assured the provider was aware of their responsibility to notify the local authority and the CQC appropriately of safeguarding concerns.

The provider understood their duty to collaborate and work in partnership with health and social care professionals. People were supported to access healthcare professionals as and when they needed them.

The provider did not always focus on continuous learning and improvement across the service. The provider did not have effective systems and processes in place to evidence that they were learning from incidents.

The provider sought regular feedback from people and relatives, by undertaking telephone monitoring and completing online surveys, however, regular care staff meetings were not in place which meant staff did not have the opportunity to learn from accidents and incidents, share good practice and raise any concerns they had as a team.

We saw that staff were supported through regular supervisions and staff we spoke with confirmed this.