Empyrean Care Group

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 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.
 

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 provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Significant improvements had been made at the service. The provider had committed to investing in quality and compliance by employing an external consultant to support with governance and oversight. Previously, quality assurance processes were not always applied consistently and were not always effective. Management and staff had not always understood the principles of good quality assurance. Policies and procedures were now in place to help shape the further direction and culture of the service, developing new systems and more robust audits for better oversight. However, these needed further development as the service grows, to ensure they continue to consistently identify and manage risk, drive improvement, and ensure these changes were sustained.

Since our last inspection, the provider had instructed an external management consultancy service to provide management support to the service. They were working in partnership with the nominated individual to ensure they were supported to become more competent in their role and driving improvement. This included an ongoing action plan, with clear objectives and regular supervision for staff.
Additionally, without a registered manager, the responsibility for managing the service rested solely with the nominated individual. The cover arrangements meant that the nominated individual was responsible for day-to-day leadership and understanding of the risks and issues they were facing, and they were not always clear about their roles and responsibilities. With the additional external support to manage the service, we saw there had been improvements made. However, there needed to be continued development to ensure they consistently identified and managed risk, drove improvement, and ensured the changes were sustained. We had received notifications in relation to significant events as per the providers regulatory responsibility.
 

The provider wanted to continue to develop a positive culture where people and staff felt they could speak up and their voice would be heard. Meetings were held and we reviewed the most recent minutes. There was a whistleblowing policy in place and guidance available to support staff in raising any concerns. This contained the contact details to the relevant organisations, and helplines for staff to raise concerns in confidence. Quality surveys were sent out to people using the service, this will continue as the service expands. Policies and systems were now in place to support them in this and continued work in this area will be required. There was a complaints policy in place, no recent complaints had been received this year.

There was no registered manager in post to deal with the day-to-day management of regulated activities. Governance arrangements had not always been effective in relation to oversight of the quality and safety of the service.

Systems to assess and monitor the quality and safety of the service had improved. New systems, checks and audits had been introduced to ensure safety and compliance. At this inspection, we found the service was moving in the right direction, however they needed to ensure the improvements were sustained and built on. A registered manager was yet to be appointed and there was a reliance at this time, on external auditors to support them. Further work was required to ensure governance systems were embedded to ensure ongoing compliance, as we were not yet able to see the full impact. For example, the provider’s governance systems had identified the improvements required to ensure consistent and sufficient details within care plans, but at the time of our inspection there was insufficient evidence to demonstrate a comprehensive oversight, due to the limited number of people using the service. This meant some systems and processes were not yet fully in place for us to assess.

Systems had been developed to engage with people, their relatives and any health professionals to obtain feedback about the service and used to share any learning. Partner agencies had limited involvement with the service due to the current low numbers of people using the service. However, there was an awareness of the need for important partnership working to continue to support people and the provider hoped to achieve this by delivering good quality services in their local community.

The provider had instructed support from an external management consultancy service with the view to make the necessary improvements and address the areas of concern found at our last inspection. They had developed a clear and comprehensive action plan which was reviewed and updated with actions from findings.
We saw evidence of staff learning and development and insight into audits completed. This would continue to be kept under review and further developed as part of ongoing quality monitoring cycle as the service expands.
Evidence was provided with recent staff meeting minutes, held to discuss what was working well and what further improvements could be made. The provider sent quality surveys to people and relatives; the responses to which were planned to be used drive further improvements.