All inspections: Empyrean Care Group - Care Quality Commission

Date of inspection 6 May to 29 July 2025
Empyrean Care Group is a domiciliary care agency providing personal care to people in their own homes. At the time of the inspection the service was supporting 1 person.

This inspection was to follow up on previous enforcement action we took against the provider at our last inspection. Their last inspection was 20 May 2024 under the name Etiquette Recruitment and Staffing Ltd and at that time we identified 4 breaches of the legal regulations in relation to safe care and treatment, staff training and good governance. We undertook this inspection to check improvements had been made and to confirm they now met legal requirements.

Since our last inspection an external management consultancy service had been instructed to provide management support and overhaul their governance systems to improve the safety and quality of the service. Overall, we found improvements had been made by the provider and they were no longer in breach of the regulations. At the time of our inspection, there was no registered manager in post to deal with the day-to-day management of regulated activities. We have requested further information in relation to this matter, to be completed within a specified timeframe for assurance.

Staff now delivered support in a person-centred way. Leaders were involved in delivering support to people for some of the week, whilst completing management tasks at other times, they were still being supported by an external consultant to do this. Lessons were identified when things went wrong, as accidents and incidents were reported and analysed. Systems were in place to protect people from the risk of abuse. People were involved in managing their risks, and staff supported people safely. Systems were now in place to monitor people’s clinical needs. Staff and leaders were being supported in their roles by way of ongoing training, supervision, spot checks and meetings.

Further work was needed to ensure the practices and systems introduced were used effectively, and more time was needed for these to become fully embedded as the service expanded. This includes ensuring leaders fully understand their responsibilities and ensure any potential risks to people’s safety are always prioritised in a timely way, learnt from, and used to embed good practice.

Date of assessment 20 May 2024 to 30 May 2024

Etiquette Recruitment & Staffing Ltd is a domiciliary care agency providing personal care to people in their own homes. At the time of our assessment, 41 people were using the service.

This assessment was prompted by concerns raised by partner agencies in relation to medicine management, assessment of risk, staffing, training, and oversight. A decision was made for us to assess and examine those risks.

During our assessment we found 4 breaches of regulation relating to safe care and treatment, safeguarding, governance, and staff training.

People’s care and support records did not adequately identify or assess risks to people. Safeguarding concerns had not always been reported to the local authority to ensure people were protected from the risk of abuse. Medicines were not managed safely. Not all staff had completed the required training to carry out their role safely. Governance systems and audits were either not in place or ineffective in identifying risk or addressing areas for improvement.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

We have asked the provider for an action plan in response to some of the concerns found at this assessment.

Etiquette Recruitment & Staffing Ltd is a domiciliary care agency (DCA). The service provides personal care to people living in their own houses and flats in the community. At the time of our inspection the service supported three people.

Why we inspected:

This was a scheduled inspection to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Rating at last inspection:

This is the first rating inspection of this service.

People's experience of using this service:

• Governance systems and audits were not effective in identifying where improvements were needed. The provider did not have processes in place to measure, document, assess and evaluate the quality of care.

• A person and people’s relative’s told us they were happy with the care people received.

• Staff training was not thorough or well organised and did not fully protect people from unsafe care.

• People were protected against abuse, neglect and discrimination. Staff ensured people's safety and acted when necessary to prevent any harm.

• People's rights to make their own decisions were respected.

• People's dietary needs were assessed and where required people were supported with their meals.

• People received caring and compassionate support from the staff.

• Staff respected people's privacy and dignity and peoples independence was recognised.

• People's care was personalised to their individual needs.

• The service met the characteristics for a rating of “requires improvement ” in some key questions and requires improvement overall.

Enforcement:

At this inspection we found the provider to be in breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Action we told provider to take is recorded at the end of the report.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Empyrean Care Group

All Inspections

During an assessment under our new approach

During an assessment under our new approach

7 March 2019

During a routine inspection