Comprehensive Care Ltd

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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service was in breach of Regulation 18 (Notification of other incidents) of the Care Quality Commission (Registrations) Regulations 2009, as they did not always send statutory notifications to the CQC when required.

This service scored 71 (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.

The registered manager and staff had a shared culture and passion for ensuring people reached their maximum potential. The registered manager was visible and accessible for staff to seek advice and guidance. Staff told us the registered manager was fair, had an ‘open door’ policy and they created a positive working culture. One staff member told us, “The registered manager is a role model to us [staff]. I am happy working here. It is like my home here, we all get on well with the residents.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was an organisational structure in place and staff understood their roles, responsibilities and contributions to the service. The management team were responsive when things went wrong and took action to make improvements. Throughout the inspection, management and staff we spoke with acted with openness, integrity and transparency.

Leaders were skilled and experienced to run the service. Staff praised the registered manager and the wider management team. Staff spoke positively about the support they received. Staff told us, “[Registered manager] is an amazing manager to be honest. They are always supporting us. We can call them at 3am and they are here, ready to help” and “[Registered manager] is perfect, more than a 100%.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and their relatives told us when they could raise concerns about their care and support when they needed to. They felt able to approach and speak with management and staff. Comments included, “I don’t have any concerns”, “If I had a problem I would tell the carer. Everything is fine” and “Office staff come monthly and check on us and the staff. I have no worries, I am happy.”

The service demonstrated a positive, compassionate and listening culture. Staff and leaders acted with openness, honesty and transparency. The service had a whistleblowing policy in place. Staff we spoke with told us they felt able to speak up about any issues and their concerns would be listened to and acted upon.

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.

The provider’s recruitment process and internal processes meant staff were recruited fairly and workforce equity was promoted. The provider employed a wide range of staff with diverse backgrounds.

Management understood the importance of having a fair and inclusive workplace. Staff received relevant training and supervision to support their knowledge and understanding of equality, inclusivity and fairness in the workplace.

Staff told us they felt they were valued, treated with respect, and the registered manager fostered an inclusive and fair environment.

The provider did not always have clear systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not always notify the CQC when required. Registered providers have a duty to submit statutory notifications to the CQC when certain incidents, such as serious injuries or allegations of abuse happen. This was a breach of Regulation 18 (Notification of other incidents) of the Care Quality Commission (Registrations) Regulations 2009.

The provider submitted the relevant notifications to the CQC retrospectively during the inspection process.

The provider’s auditing systems were not robust. The provider had a range of checks and audits to monitor the quality and safety of the service and to help drive improvements.However, auditing systems did not pick on the issues we found during this inspection around non submission of notifications to the CQC and staff recruitment checks.

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 service worked in partnership with other health and social care organisations to achieve better outcomes for people using the service. There was a good working relationship with commissioners and health teams. People received a holistic level of care and their support needs were safe and effectively managed.

Management and staff worked collaboratively to help people access their community and to achieve increased independence. They worked positively with a range of partners at multi-disciplinary team meetings when reviewing people’s changing needs. Staff worked well with other professionals.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Processes were in place to ensure learning happened when things went wrong. They also shared examples of good practice to support further learning. The provider had implemented learning from this CQC inspection and had implemented new processes to drive service improvements. The registered manager sought guidance and advice following our feedback regarding their own responsibilities in submitting relevant statutory notifications to us.

Surveys had been issued to people, their relatives and staff, results were analysed and action plans were created to drive service improvements.

As part of this inspection, we spoke with people and relatives about their experiences of the care and services they received. Feedback from people was positive, however, feedback from relatives was mixed. Although a lot of relatives were happy with the care and communication from the provider, other relatives wanted more contact and were unsure whether the level of care their relative received was adequate for their needs. We fed this back to the registered manager, who took the information on board and showed a commitment in improving services for people. The registered manager also explained they valued feedback from people and relatives and were continuously working to obtain regular feedback so they could resolve issues and drive improvements.