Date of Assessment: 21 August 2025 to 24 October 2025. The service is a care at home service providing support to children and adults of all ages living with dementia, mental health conditions, physical disabilities, sensory impairments, learning disabilities and autistic people. At the time of our assessment the service supported 87 people. We inspected the service due to risks about people’s care calls not being delivered as they should be and we wanted to ensure people were in receipt of care to meet their identified needs. People were involved in the assessments of their own needs which were regularly reviewed. However, changes were not always updated in people’s care documentation which meant people’s records were not always accurate and could affect support provided by staff. Despite this, staff knew people’s needs well. Staff worked with other organisations involved in people’s care to make sure people’s care needs were met. Staff helped people understand their care and treatment so they could make choices. If someone couldn’t decide for themselves, staff talked to family or others who know them well to make the best decision for them. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas. We have 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.
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Passion 4 Care is rated Good overall at its first CQC inspection, with Safe rated Requires Improvement due to incomplete skin-check recording and inaccurate medicine administration records for one person. All other key questions were rated Good, reflecting strong person-centred care, consistent staffing, effective multi-agency working, and a responsive, open leadership culture.
Concerns (2)
moderateRecord keeping: “Staff did not always effectively record the monitoring of risks to people. For example, one person required regular skin checks, however staff had not recorded when this had been completed.”
moderateMedication management: “We found for one person, where their medicines were to be taken once daily, their MAR showed staff had recorded these up to four times a day for the month of July.”
Strengths
· People had consistent staff who arrived on time and never missed calls, with relatives confirming correct staffing levels were always maintained.
· Staff were trained to recognise and report abuse, and people and relatives confirmed they felt safe.
· Care plans were person-centred, detailed individual preferences, and were developed with involvement from people and their relatives.
· Staff worked closely with GPs, district nurses, and other health and social care professionals to meet people's needs.
· An open and honest culture was maintained, with management accessible and supportive of staff.
Quality-Statement breakdown (25)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
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 and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood