Date of Assessment: 20 January to 20 February 2026. The service is a care at home service providing support to older people and adults of all ages some of whom were living with dementia. Some people had nursing needs, mental health conditions and physical disabilities. There was a positive learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. Service audits were regular, well embedded, thorough and helped the provider to maintain good standards of support to people and their families. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all the appropriate agencies involved in people’s care to produce the best outcomes for them. They monitored people’s health to support healthy living. Staff made sure people understood their care and treatment plans to enable them to give informed consent. Where people did not have capacity to give consent, the provider involved the appropriate people, including relatives and families, to ensure people’s best interests were met. People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choices in their care and were encouraged to maintain relationships with family and friends. Staff responded to people in a timely way. The provider supported staff wellbeing. People were involved in decisions about their care. Staff provided information people could understand. People knew how to give feedback and were confident the provider took it seriously and acted on it. The service was easy to access. People received fair and equal care and treatment. Staff worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care. 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. People with protected characteristics felt supported. 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. The reason for this assessment was to monitor improvements made by the provider following the last inspection we carried out in September 2023. Then we found breaches in Regulations 9 [Person Centred Care] of the HSCA RA Regulations 2014; Regulations 13 [Safeguarding]; Regulation 16 [Receiving and acting on Complaints]; Regulations 18 [Staffing]; Regulation 12 [Safe care and treatment] and Regulations 17 [Good governance]. These breaches have been fully met at this assessment. Improvements were found in all areas and the provider was no longer in breach of these regulations. This service has been in Special Measures since September 2023. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. After this assessment the rating has improved to good overall and in each quality statement.
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Compassion Home Care Limited was rated Inadequate overall following inspections in September 2023, with breaches of Regulations 9, 12, 13, 16, 17 and 18 identified across unsafe medicines management, absent or inadequate risk assessments, failure to make safeguarding referrals, ineffective governance, and staff lacking condition-specific training and regular supervision. The service was placed in special measures, having deteriorated from a Good rating last awarded in November 2017.
Concerns (14)
criticalCare planning: “Risk management plans were either not in place and/or not detailed to ensure that there was up to date person-centred guidance for staff on what to do should people become ill.”
criticalMedication management: “Medicines were not always safely managed. The provider did not always maintain accurate medicine administration records.”
criticalSafeguarding: “The provider had not made any safeguarding referrals since the last inspection in 2017. Whilst accidents in relation to a pattern of unexplained bruising or a fracture were recorded, they were not investigated.”
criticalStaff training: “Staff had not undertaken training that was relevant to the people they were supporting. This included epilepsy, diabetes, Parkinson's disease and catheter bag training.”
criticalGovernance: “Quality assurance processes had failed to effectively identify and address the issues identified during this inspection. Staff told us that care plan audits had ceased when the provider moved to an electronic system in November 2021.”
moderateIncident learning: “Accidents and incidents were not analysed for trends/themes and learning was not always disseminated to staff so there could be a positive impact in improving people's experience.”
moderateStaff competency: “There was no process in place to assess staff competency to ensure they had the right skills and know to carry out their roles effectively.”
moderateSupervision / appraisal: “Staff files reviewed, and staff spoke to confirmed that staff were not supported with regular 1:1 supervisions. One staff member said, 'Last supervision I had was 2-3 years ago.'”
moderateConsent / capacity: “The registered manager and some staff were not able to demonstrate a clear understanding of the principles of MCA and when it should be applied.”
moderatePerson-centred care: “People's care plans were not always person-centred and contained minimal information about people and their health and care needs.”
moderateComplaints handling: “The registered manager told us that they had not received any complaints to date. However, we saw a number of incidents that should have been classified and investigated as complaints.”
moderateRecord keeping: “Robust records, which included risk assessments and care plans were not always accurate or complete.”
minorMissed or late visits: “The system calculated 5 minutes between calls that was not a realistic amount of travel time. They said that this meant they were late for the next call.”
minorCommunication with families: “Some staff told us they were hesitant to contact the registered manager for advice and guidance as communication with the registered manager needed improving.”
Strengths
· Appropriate recruitment checks were carried out before staff joined the service, including DBS checks, application forms and references.
· People were protected from the risk of infection; staff always wore PPE such as aprons, gloves, masks and shoe covers.
· People told us that they felt safe and had the same regular carers for consistency.
· The provider liaised with relevant agencies such as district nurses and GPs when required.
· A survey carried out in 2022 showed overall very positive feedback from people using the service.
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choicesRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
Compassion Home Care Limited was rated Requires Improvement overall at its August 2016 inspection, with care planning and risk assessments not consistently updated following changes in people's needs, safeguarding refresher training out of date, and formal internal audits absent. The service performed well in caring, effective and responsive domains, with staff described as kind, competent and punctual, and people reporting high satisfaction with personalised support.
Concerns (4)
moderateCare planning: “Risk assessments and care plans were not always updated when there had been a change in the person's needs to ensure that staff had the appropriate guidance when offering the person support.”
moderateRecord keeping: “one person had undergone an operation. We found that their care plan had not been updated after this event to identify the risks involved or any guidance for staff”
moderateStaff training: “We found that safeguarding training for all staff was not up to date.”
moderateGovernance: “audits to monitor and assess the quality and safety of the service had not been carried out... the provider did not undertaken medicine audits to check the quality of medicines records”
Strengths
· People felt safe with care workers and staff demonstrated clear understanding of safeguarding procedures and whistleblowing policy.
· Appropriate recruitment checks were conducted before staff started work, including references, identity and DBS checks.
· Electronic call monitoring system in place; no missed calls and staff punctual on the day of inspection.
· Staff received regular supervisions, annual appraisals and spot checks in the community.
· People were treated with kindness, dignity and respect; care was personalised and person-centred.
Quality-Statement breakdown (17)
safe: Risk assessments updated following changes in needRequires improvement
safe: Safeguarding procedures and staff awarenessGood
safe: Medication management and MAR recordsGood
safe: Recruitment checksGood
safe: Staffing levels and call monitoringGood
effective: Safeguarding refresher training currencyRequires improvement
effective: Staff induction, mandatory training and supervisionGood
Compassion Home Care Limited was rated Good across all five key questions at its October 2017 inspection, having successfully addressed the Requires Improvement findings from June 2016 relating to risk assessments and staff training. The service demonstrated strong person-centred care, robust safeguarding practices, effective quality assurance, and a supportive open-door management culture.
Strengths
· Staff trained in safeguarding and understood reporting procedures, with clear escalation pathways including whistleblowing
· Robust risk assessment process covering pressure sores, moving and handling, nutrition and home environment with specialist input
· Electronic call monitoring system to detect and respond to late or missed visits
· Staff received regular supervision, spot checks, observations and one-to-one feedback
· Strong end of life care delivered in partnership with palliative care teams and GPs, in line with people's wishes
Quality-Statement breakdown (23)
safe: Safeguarding people from abuseGood
safe: Risk assessment and managementGood
safe: Staffing levels and recruitmentGood
safe: Medicines managementGood
safe: Incident and accident managementGood
effective: Staff training and inductionGood
effective: Supervision and supportGood
effective: Mental Capacity Act complianceGood
effective: Supporting people to live healthier lives and access healthcare servicesRequires improvement
effective: Supporting people to eat and drink enoughRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
responsive: Planning personalised care to ensure people have choice and controlRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Meeting people's communication needsRequires improvement
well-led: Managers and staff being clear about their roles; continuous learning and improving careInadequate
well-led: Engaging and involving people using the service, the public and staffInadequate
well-led: Promoting a positive, person-centred and open cultureInadequate
well-led: Working in partnership with othersGood
effective: Nutritional needs and healthcare accessGood
caring: Kindness, dignity and respectGood
caring: Person-centred approach and involvement in care planningGood
responsive: Care plan updates following changes in needRequires improvement
responsive: Person-centred care plans and regular reviewsGood
responsive: Complaints handlingGood
well-led: Internal audit and quality monitoring processesRequires improvement
well-led: Leadership culture, staff support and open-door policyGood
well-led: Engagement with people using the serviceGood