Empyrean Care Group

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 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.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Since our last inspection, the provider had developed a more proactive and positive culture of safety. They had now implemented a system to report, review and analyse accidents and incidents that occurred. Lessons were identified when things went wrong, as accidents and incidents were reported and analysed. These were shared with staff during staff meetings.

Previously care plans and risk assessments had not always been fully completed or updated when changes had occurred. We saw evidence that systems were now in place to ensure information was updated as changes occurred for people and shared to staff with any new details in relation to the care needs.

As there had been no new packages taken on, there was insufficient evidence to demonstrate how the provider would work well with people and healthcare partners to establish and maintain safe systems of care.

Information about people’s needs was recorded, shared and understood by staff. The providers policies had information on how and when to make referrals to relevant agencies but had not yet been fully utilised. Initial assessments were completed; risk assessments and care plans were in place with reviews scheduled to identify if any change of needs. Due to only a small number of people who had used the service, further time was needed to ensure safe practices in systems, pathways and transitions were fully embedded.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider now initiated internal investigations and took actions to improve safety where concerns about abuse were reported. This ensured people were protected from the risk of abuse or harm. Safeguarding was routinely discussed with staff, which helped to promote awareness of safeguarding.
Training records showed staff had completed mandatory safeguarding training and recognition of deprivation of liberty safeguards (DoLS). DoLS are required to protect individuals who lack mental capacity within care settings.
 

The provider worked with people to understand and manage risks; however, they had not taken any new packages which meant there was limited information to review. Staff provided care to meet the current person’s needs to ensure their care was safe, supportive and enabled them to do the things that mattered to them.

At our last inspection, we found risks to people were not always identified or assessed. During this inspection we found improvements had been made and risks were now identified and assessed. We reviewed daily records, demonstrating people’s care was supporting their needs. The provider was aware of the improvements required regarding any future packages, care plans and risk assessments, and work was in progress to continually review the existing records and to address this.
Improvements had been made in ensuring people and their relatives were involved in their care planning, or in assessment of risks and reviews of people’s care.
The provider had rolled out specific training to ensure staff were confident in supporting clinical risks to people such as diabetes care.
 

The provider had only 1 staff member in addition to themselves working in the field. As the packages increase, further staff will be required to support people safely. The provider had ensured the current staff were qualified and skilled

With only 1 person to support currently, the staff group consisted of the nominated individual and 1 staff member. There were safe recruitment systems in place for the future, to help ensure only suitable staff were recruited. These included checks on the staff’s identity and to check for the right to work in the United Kingdom. Staff logged in and out of the care calls, and this was audited in relation to time and duration of calls. Staff had received supervision and appraisals, as well as completing the training identified as necessary to meet people’s needs, and to enable them to continue to develop their skills. People were cared for by the same staff who knew them well, Plans were in place to increase the staff team slowly, when more packages were obtained and the need identified.
 

The provider had made sure the medicines and treatments for their current package was safe, meeting their needs, capacities and preferences. Staff involved the person in decisions and planning in relation to their medicines. However, they had not taken on any new packages which meant there was limited medicine information to review.

Clear guidance was now in place to support people who were prescribed medicines. The electronic system prompted staff in relation to administering medicine. Medicines training was completed before supporting people with them. Medicine records were fully completed to reflect the person had received their medicine as prescribed. Informal checks, audits and competency assessments were completed to ensure safety in delivering support with medicines. The provider understood the importance of working closely with any healthcare professionals to support people’s health and wellbeing.