Compass Care – South Park improved from Requires Improvement to Good across all five key questions, having remediated previous breaches of Regulations 12 and 17. Two recommendations were made regarding safeguarding incident reporting and recruitment record-keeping, but no breaches of regulation were identified at this inspection.
Concerns (2)
moderate
Safeguarding
: “incidents, whilst recorded, were not always reported to the required agencies, for example the local authority. The provider took action to address this at the time of inspection.”
minorRecord keeping: “some checks were not consistently recorded, for example, gaps in employment history. The provider took action to address this at the time of inspection.”
Strengths
· Person-centred care records reflecting individual needs, choices and preferences, with people actively involved in care reviews.
· Effective infection prevention and control systems in place following previous breach; environment clean and tidy.
· Medicines managed, stored and administered safely with STOMP principles understood by staff.
· Strong partnership working with healthcare professionals, who described care as compassionate and of very good quality.
· Open, positive culture led by a registered manager with good oversight, supported learning and improvement from accidents and incidents.
Quality-Statement breakdown (24)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Using medicines safelyGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to live healthier lives and access healthcare services; staff working with other agenciesGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Staff support: induction, training, skills and experienceGood
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: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control; end of life care and supportGood
responsive: Supporting people to develop and maintain relationships; support to follow interests and activitiesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Continuous learning and improving careGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candourGood