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Date of Assessment: 13 to 28 January 2026. The service is a care at home service providing support to adults of all ages including those living with dementia, mental health conditions, physical disabilities and learning disabilities and autism. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. Although the management team were not fully aware of this guidance, the processes in place overall helped to ensure care was provided in an individual and supportive way. Compassion Care 24/7 Supported Living Limited provided a caring and personalised service where people and relatives consistently described positive experiences of the care they received. Staff described the culture as supportive, and many told us they felt valued and treated well. However, although people experienced positive day‑to‑day care, we found significant shortfalls in the provider’s governance and oversight systems. Important elements of safe and effective care were not consistently embedded or monitored. Risk assessments were incomplete or missing for several people, including those at risk of falls, choking, pressure damage or needing support with complex medical conditions. Care plans lacked essential clinical detail, including information about medicines, monitoring requirements, allergies, medicines which increased the risk of bleeding not risk assessed, Medicine Administration Records required improvement with missing signatures and PRN (as‑needed) medication protocols, were not in place. Staff described relying on care plans, but the information within them was not always sufficient to guide safe decision-making. Formal process to comply with the Mental Capacity Act were not in place. Recruitment checks were incomplete in several staff files, and duty rosters contained overlapping calls with no allocated travel time, which posed a risk of rushed or shortened care. Staff confirmed these issues sometimes made it harder to deliver care safely and on time. Leaders engaged well during the inspection, acted promptly on feedback and demonstrated willingness to improve. They began updating care plans, introducing information sheets for emergencies and developing a more structured governance approach. Despite these concerns, staff were committed and compassionate, and feedback from people, families and many staff members was consistently positive about the care provided. Infection prevention and control risks were well managed. People were supported by consistent staff and staff were positive about the training they received and day to day support from the management team. The provider was in breach of legal regulations relating to risk assessment, medicines management and governance.
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