Embrace UK Community Support Centre is rated Good overall following a comprehensive inspection in November–December 2022, having improved from Requires Improvement at the previous inspection. Well-led remains Requires Improvement due to inconsistent record keeping, insufficient audit rigour, and poor communication with some families, with a recommendation to seek guidance on effective monitoring and record keeping.
Concerns (6)
moderate
Staff training
: “Safeguarding training had not always been effective as some staff due to English not being their first language struggled to understand what they were being asked.”
moderateSafeguarding: “Some staff struggled to understand what they were being asked about abuse and did not understand whistleblowing procedures, therefore could not explain the action they would take.”
moderateGovernance: “Audits were not always clear due to contradiction in information and records were not always accessible...risk assessments were not in people's files.”
moderateRecord keeping: “Not all information about people's choices were recorded, for example, food and drink choices. Records were not always accessible, risk assessments were not in people's files.”
moderateCommunication with families: “The company has poor communication...when I ring, they do not pick up. The service is not well managed or led. The service delivery is poor.”
minorMissed or late visits: “Call logs covering 10 October 2022 to 6 November 2022 showed some staff were frequently late and where 2 staff were needed, this did not always happen.”
Strengths
· People and relatives consistently reported feeling safe with care staff and praised their kindness, compassion and professionalism.
· Robust recruitment checks in place including enhanced DBS, references and identification verification.
· Risk assessments were completed and reviewed across multiple risk areas including skin integrity, medication, falls and mobility.
· Staff were matched to people based on skills, cultural background and language needs.
· Improved complaints handling system implemented since last inspection with logging and analysis of complaints.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support; induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough with choice in a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective and timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candourGood