Compassion Care 24/7 Supported Living Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.
This is the first inspection for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of the legal regulation relating to risk and medicines management.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Systems and processes did not support effective learning when incidents occurred. For example, a person had a fall with injury which was not recognised or managed appropriately. Body maps were present but had not been updated, and management oversight had not identified this until the inspection.

Staff felt able to speak up and describe learning from incidents and complaints. One staff member said, “You learn from any mistakes, making sure things are updated when needed so we minimise mistakes.” People and relatives told us staff acted quickly to resolve issues, and a person said the office team “sorted it out straight away.”

Leaders used duty of candour appropriately and took steps to retrain staff when errors occurred, such as after a medication issue or concerns about bed rails. Some governance gaps meant leaders did not always identify learning needs promptly, but actions were taken once issues were raised.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service had systems in place to support safe transitions. Staff told us new assessments helped them understand people’s needs, with a staff member explaining, “The senior carer will go with the manager to assess them, so we know our job before we go there.” People and relatives said staff were flexible and responsive when needs changed. A family member told us, “They take [Name] to hospital appointments. they are very helpful.” Leaders agreed to introduce hospital passports and information sheets after gaps were identified. This would help ensure external health professionals were more aware of people’s individual needs when making clinical decisions especially in emergencies.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. One person was receiving 24-hour live-in care and office staff confirmed that the person lacked mental capacity to consent and was under continuous monitoring. The provider had not ensured that a referral for a community Deprivation of Liberties Safeguards [DoLS] had been made. Office staff agreed to make the necessary referrals to the local authority.

Otherwise, the service concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. People and relatives consistently told us they felt safe. One person said, “They are very gentle with me,” and another told us staff “have never let us down.” Staff understood safeguarding responsibilities, with 1 stating, “I would record it and call the office, they will take action.” Staff were confident leaders would support them when raising concerns. Policies were comprehensive, and staff could explain the actions they would take if someone showed signs of harm or neglect.

The provider did not always work well with people to understand and manage risks. Risk management was not effective. Risk assessments did not cover all relevant risks. Several people’s risk assessments were incomplete or lacked clear instructions for staff. For example, a person at extreme risk of falls, a person at risk of skin damage, and people with specific health conditions did not have sufficient mitigation guidance. A choking risk assessment did not include information about texture of meals to reduce the risk of choking or actions for staff to take. There was a lack of clear escalation instructions, especially for falls and inconsistent mitigation guidance for staff. Several care plans lacked essential assessments and clear actions for staff to follow.

Staff described relying on care plans and the providers electronic app, but documentation did not always include key risks such as falls, choking or deterioration. This meant staff may not have all the information they required to manage risks and respond appropriately. Leaders began updating risk assessments during the inspection, but systems had not ensured risks were consistently identified and managed.

The provider detected and controlled most potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Home environments were considered at assessment, and people felt their care staff followed safe practices. However, some environmental risks were not fully documented, including fire safety responsibilities. While these gaps required improvement, there was no evidence of unsafe practice during care delivery. People confirmed staff used equipment safely and maintained hygiene in their homes. One person told us, “They always clear up after themselves when using the bathroom or kitchen.” Staff said they had training to use equipment and could access additional items through the office.

The provider made sure there were enough qualified, skilled and experienced staff. However, rosters included overlapping calls and no travel time. One staff member said, “Sometimes you have 2 calls at the same time and have to manage them yourself.” Recruitment files also lacked complete employment histories and references. The management team undertook to complete a full review of recruitment records and seek any identified missing information.

Staff received effective support, supervision and development and worked well together to provide safe care that met people’s individual needs. Training was up to date and covered relevant topics. Where care staff failed to undertake required training, they were removed from duty rosters pending its completion. Staff were positive about their induction and ongoing training. In September 2025 a new code of practice came into force which required all providers to ensure training for learning disabilities and autism meets The Oliver McGowan Mandatory Training on Learning Disability and Autism legislation. Although all staff had done some autism or Learning Disability training this did not meet the required content of the legislation.

People and relatives felt staffing was consistent, and praised individual staff members, describing them as “kind,” “professional,” and “very flexible.” A person told us, “They pretty much turn up on time, and I have never had a missed call.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People said staff followed hygiene routines well. One person told us, “They [care staff] wear gloves and aprons and always wash their hands. They are very professional.” Staff confirmed they had Infection Prevention and Control training and could access Personal Protective Equipment [PPE] easily, with one saying, “There is always some in people’s homes and we can get more from the office.” The service had a comprehensive infection control policy that met expected standards.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Care plans lacked essential medicine‑specific information, anticoagulants [medicine which reduces the risk of blood clotting] did not have completed risk assessments, handwritten Medicine Administration Records lacked signatures or clear instructions, as required medicines protocols were not in place, allergies were missing from some Medicines Administration Records and body maps were not used consistently. Leaders began updating documents during inspection, but oversight systems had not ensured safe practice before this.

People and relatives were positive about how staff supported medicines. One family member said, “They [staff] sort out the medications and keep me in the loop.” Staff told us they had completed training and competency checks, and one said, “If medicines are running low, we tell the office or the family.”