Empyrean Care Group

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last published inspection, we rated this key question requires improvement. At this inspection the rating remains the same. This meant some aspects of the service only had limited assurances about safety and there was an increased risk people may be harmed.

At our last inspection the provider was in breach of the legal regulation in relation to safe care and treatment with accidents and incidents going unreported, pre-admission assessments and plans not completed sufficiently for staff to be able to support people safely, risks were not always identified or assessed, and not all staff had completed the required training to carry out their roles. Due to poor oversight and systems, we could not be assured that people had received their medicines as prescribed.

At this inspection improvements had been made, and the provider was no longer in breach of the regulations. However, as there were limited people using the service and only a very small staff team, further work was required to ensure the changes were embedded to maintain ongoing compliance, as we were not yet able to see the full impact with a larger service.

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 published inspection, we rated this key question requires improvement. At this inspection the rating remains the same. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At our last inspection the provider was in breach of the legal regulation in relation to good governance. They did not have the governance systems in place to provide oversight of risk and identify areas for improvement. Policies and procedures had not been followed, and the registered manager had not completed audits and did not understand their regulatory responsibilities.

During this inspection improvements had been made, an external consultant was supporting with governance, and the provider was no longer in breach of this regulation.
Systems to assess and monitor the quality and safety of the service had improved. New checks and audits had been introduced to ensure safety and compliance. However, these needed further development to ensure they continued to identify and manage risks. The service was moving in the right direction. The previous registered manager was no longer employed in this role.