Compass Care Derbyshire Ltd

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 good. This meant people were safe and protected from avoidable harm.

This service scored 78 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and events within the service were recognised, reported and acted upon. The provider effectively monitored for any themes or trends from incidents. Staff morale was good and the team enjoyed working with the provider. There was a good sense of teamwork. Lessons were learnt to continually identify and embed good practice. We found the registered manager was open and transparent in driving improvement for the service and had a clear direction for the future ensuring people would be able to achieve the best outcomes possible.

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 provider had procedures in place to ensure people’s transitions to and from other services was well-managed, involving people, their families and any relevant healthcare professionals in the discussions. This included an initial assessment of needs at the start of the service, and a clear plan of care completed with the person and any involved relatives. People were continued to be supported to access external health care professionals to improve and monitor their well-being.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The person told us they felt safe with staff as they knew them well and gave them the support that they needed.

Staff received regular safeguarding training. The provider had a safeguarding policy and procedure in place; to support effective and timely safeguarding. Staff told us they knew how to report any concerns and what they would do, if they suspected any abuse had occurred.

The registered manager confirmed they carried out investigations and co-operated with any safeguarding enquiries required by the Local Authority. These findings were used by the registered manager to identify any lessons learned and any further actions to be taken to ensure people continued to be protected from abuse.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The person’s care records included information around individual risks and the support staff needed to provide. For example, risks around mobility and equipment use, skin integrity and specific health conditions were all assessed and information regarding any involved healthcare professional advice was recorded. Information about changes in the person’s care needs was shared with staff so support could be changed to reduce any recurrences. Care plans included risk assessments relating to the health, safety and welfare of the person.

The person we spoke with confirmed that staff supported them to balance safety with individual choice. This meant people, and their relatives where appropriate, were involved in deciding how their individual risks would be managed and mitigated.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

In people’s own homes, CQC does not regulate the environment in which people live. However, we do ensure people’s safety is still assessed and monitored.

The provider had environmental safety assessments in place to identify any potential risks in the person’s home which may have an impact on the person or their care staff. This included making sure the environment was a safe working space for them to deliver care. Any potential environmental concerns were discussed with the person receiving care, as the provider was mindful it was the person’s own home.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Staffing arrangements were centred around the person’s individual funded hours, assessed needs and personal preferences. The provider carefully considered compatibility when recruiting and allocating staff, recognising the importance of meaningful relationships in achieving positive outcomes. The person told us they had been actively involved in recruiting their staff team, giving them confidence that staff understood them and were the right fit. They spoke positively about being able to choose which staff supported them with activities based on shared interests and strengths. For example, they enjoyed gardening, cooking and crafting with staff who had similar passions, which enhanced their enjoyment, independence and wellbeing.

We reviewed the training records for staff and found it included mandatory training as well as specific individually crafted training related to the needs of the person. Staff commented that training was good and gave them the skills to carry out their role. One shared, “All training is thought out, easily accessible and renewed in a timely manner, there are further opportunities to advance skills with external courses”.

The provider had a recruitment procedure to ensure staff were suitable to work with vulnerable people. We reviewed a selection of staff records and found all pre-employment checks had been completed prior to staff commencing in post. Staff also received supervision and support to strengthen teamwork and professional development.

The person benefited from a stable and carefully recruited staff team who understood their needs, preferences and goals. The provider’s strong focus on recruiting the right people, investing in tailored training and fostering a positive learning culture helped create a skilled, motivated and dedicated workforce. This enabled staff to deliver care that was not only safe and effective but also enriched the person’s quality of life and promoted meaningful outcomes.

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.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The provider ensured their staff had access to the necessary personal protective equipment (PPE) to support effective hygiene and infection prevention.

The provider’s infection prevention and control (IPC) policy and procedures set out the roles and responsibilities for staff around infection prevention and control to ensure this was managed safely.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Where people needed assistance with their medicines, these were administered in line with relevant legislation. Although people’s medicines were sometimes managed by the person themselves, or their relatives, the provider worked with people to ensure they had the necessary prescribed medicines available to them.Up-to-date information about their medicines was available in people’s care plans and the provider’s medicine records. The provider made sure people’s individual records specified exactly what support each person needed from care staff in respect of their prescribed medicines, including the application of prescribed creams.

The provider carried out regular medicines audits to identify any errors in recording and to check staff competencies.