Empyrean Care Group

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• 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

We identified 1 breach of the legal regulations.

The service was not well led. There were no governance systems in place which provided oversight of risks and areas for improvement. The registered manager completed no audits and did not demonstrate an understanding of their regulatory responsibilities. Policies and procedures were in place but not followed. This placed people at risk of harm.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders were not able to demonstrate they shared the same vision and priority to provide high quality and safe care. This was because the policies and procedures in place to support the delivery of the service were not consistently followed. For example, accident and incident reporting policy highlighted the importance of recording and reporting accidents and incidents but this was not completed.

Policies and procedures were in place to help shape the direction and culture of the service; however, these were not always followed. Lack of effective oversight meant the needs of people using the service were not always identified and therefore action wasn’t taken to address them.

The provider’s statement of purpose was not up to date and did not reflect the service provided. For example, it stated the provider would ensure robust comprehensive risk assessments were in place for service users and ensure the registered manager was adequately trained. A statement of purpose is a legally required document which sets out information about the service provided.

We received feedback from staff that leaders were not always visible within the service. Most staff referred to the care co-ordinator to raise concerns or seek support.

Leaders did not demonstrate they were suitably skilled or competent to lead effectively. At the time of our assessment the registered manager had not completed any mandatory training. Leaders did not demonstrate an understanding of their regulatory responsibilities. This included the requirement to submit statutory notifications to CQC.

Lack of systems and processes to oversee the service meant staff and leaders were not aware of the issues and priorities for the service. Some external audits had been completed, but the provider failed to take action where areas for improvement had been identified.

Overall, people and staff felt able to contact the care coordinator at the service. There were opportunities for staff to feedback through meetings.

There was a whistle-blowing policy in place and guidance available to support staff in raising concerns. However, processes for managing whistle-blowing concerns were not in place, audited or understood. For example, lack of reporting and information sharing with relevant agencies where concerns were raised. Quality surveys were sent out to people using the service; however, results were not analysed or actions generated to address themes for improvement.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

During our assessment leaders told us their priority was compliance. Leaders told us they carried out some checks of the service, but these were not recorded. We were not assured these checks were robust as concerns were identified during our assessment which leaders were not aware of or had taken any action on. For example, we were told daily checks of medicines were completed. There were no records of these, and we found significant numbers of missed doses recorded which had not been reviewed or followed up by leaders.

Governance and quality assurance policies were in place which set out how the provider would ensure clear and effective governance, management, and accountability arrangements, however there were widespread failings to ensure these policies were followed. For example, there were no quality audits completed and therefore the provider was unable to demonstrate how they had oversight or risk, or areas for improvement within the service. Many of the concerns identified during our assessment had failed to be identified or acted on to mitigate risk because of lack of governance systems. This placed people at risk of harm or receiving poor quality care.

People and relatives we spoke with told us they managed referrals to relevant healthcare professionals themselves, however felt assured staff would alert them to any changes or concerns that required attention. However, we were unable to see any evidence that relevant authorities and agencies were consulted with appropriately. During our assessment we identified people had experienced situations or issues in which healthcare professionals and safeguarding authorities should have been informed but they had not. This included missed medicines, staff carrying out tasks which they had not been trained for and staff not sufficiently checking on the safety and well-being of people.

Partner agencies shared they were not always able to get in touch with the registered manager. We received positive feedback on the working relationship with the care coordinator from the local authority.

There were no processes in place to ensure relevant partner agencies were consulted with where required. This included referrals to healthcare professionals, or information sharing with the local authority. Leaders did not always demonstrate how they engaged with partner agencies to improve people’s outcomes and were not always aware of who the appropriate authorities were. Staff shared some previous examples of working with other agencies but confirmed at the time of our assessment they were not working in partnership with any other professionals.

Leaders continued to keep us updated by sharing an ongoing action plan following our assessment. Whilst this identified areas for improvement, it failed to provide sufficient assurance the significant areas of concern identified during our assessment had been addressed. Staff told us they were not always aware of current service priorities or areas for improvement.

People and relatives were asked for their feedback, but this was not used to drive improvements. The provider sent quality surveys to people and relatives. There was no review of the results or actions generated to drive improvement. The most recent survey showed themes relating to timeliness of staff, however there was no evidence this had been addressed.