Compassion Care 24/7 Supported Living Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection for this service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders promoted a clear aim of delivering person‑centred, compassionate care. Staff understood the values of the service and described a positive ethos. One staff member said, “They [management team] listen to ideas.” People and relatives frequently praised the office team, naming individual office staff for being “lovely and helpful”. The culture was open and supportive, and staff felt motivated.

Not all leaders understood the context in which the provider delivered care, treatment and support. As detailed in previous sections of this report we identified that leaders lacked oversight of key areas including risk assessments, medicines systems and Mental Capacity Act compliance. Leaders were not fully aware of national frameworks such as Right Support, Right Care, Right Culture, which limited assurance that these principles were consistently embedded for people with autism or learning disabilities. While leaders were caring and committed, these gaps meant leadership capability required strengthening. Leaders were visible, and staff described them as supportive. One staff member said, “Any problems, they sort it out,” People and relatives told us the office team knew them well and were responsive.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Most staff felt confident to speak up and understood the whistleblowing policy. They told us they could raise concerns with managers at any time. A staff member said, “Yes, I feel able to raise concerns,” while another said they would escalate issues further if needed, adding, “If I am not satisfied with the response, I would contact safeguarding.” Staff said they felt listened to and that leaders acted on concerns. The majority of care staff felt safe and empowered to speak up.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. People received care from a diverse workforce, and staff described fair treatment. One staff member told us, “Yes definitely, we are treated fairly,” and another reported, “My human rights are being upheld.” Leaders supported international staff with personal and practical matters when required. Staff said requests for flexibility, such as childcare or medical appointments, were accommodated. People and relatives confirmed staff respected cultural and personal preferences. Overall, the workforce felt valued and included.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were not effective. Significant shortfalls such as missing risk assessments, lack of clinical monitoring and unsafe medicine administration practices had not been detected prior to inspection. The inspection also identified gaps in recruitment checks, Mental Capacity Act compliance, monitoring systems and auditing. Leaders acknowledged that governance was “informal” and had not identified issues prior to inspection. Care records lacked essential detail, were inconsistently completed and not always signed or dated, which limited oversight. Rosters contained overlapping calls and no travel time, and leaders had not identified this risk. Although leaders responded positively to feedback and began making improvements, they accepted these actions would not have been undertaken without inspection. These systemic weaknesses meant governance required significant improvement.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider maintained constructive relationships with external partners and was open to support. People, relatives and staff described positive engagement with GPs, district nurses and social workers. One relative said carers, “helped me get more care for [family member] when they were trying to discharge them out of hospital too early”. Staff said external professionals responded quickly when contacted and that communication worked well. Leaders described engaging with community networks, such as local meetings and social support organisations. There were no concerns about partnership working, and evidence showed collaborative approaches were supporting people’s care.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The service demonstrated willingness to improve and responded promptly when gaps were identified. Leaders updated care plans, implemented hospital passports and created action plans soon after receiving feedback. Staff described learning from incidents, including medication errors and equipment‑related risks. However, systems to identify learning needs independently were not embedded, and formal feedback collection from staff and stakeholders was limited. While early changes showed promise, sustained improvement required stronger governance and monitoring systems.