Archived: Comfort Call- Leeds

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 key question has been rated good. However, we identified a breach of regulation as quality assurance processes and procedures had not always been effective.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they understood the values of the service. Their comments included, "The values and visions are making impact in people’s lives and making a difference in their lives." and "The visions and values is to prioritise the service user, make them happy, make them feel inclusive." The registered manager explained the actions they had taken to improve staff's wellbeing, moral and engagement within the service. During our inspection, staff reported feeling well supported by the management team.

The service recognised staff's work and sent cards and postcards to celebrate events and show recognition for their work. The service recognised staff's work by organising events that promoted team building.

Staff told us they felt supported by management. Staff told us, "I feel supported in my role" and "Management use person centred care for service users and management are very professional, friendly, straight to the point. They are approachable and fair, the treat new ones the same way they treat staff who had been there for years."

The service had developed an 'extraordinary people board' where compliments made to staff by people and relatives were recorded in the office. The aim was to encourage and recognize staff for the good work completed and positive impact on people's lives.

Staff told us they could raise concerns and management would take action. Their comments included, "I am able to raise concerns with the manager. We were trained to speak up when we have any concerns. Management is approachable" and "Yes, I can raise any concerns with the manager. Management are approachable and fair to staff. I do ask feedback about improvements; I had a client whom I suggested they are better off in a care home; they listened to me and said they will speak to the family about it." The service was conducting regular staff meetings. Minutes reviewed as part of this inspection showed conversations about feedback from staff about their communication with the office and actions taken to improve wellbeing, such as staff check in call. Appropriate action to act on staff's feedback. During this assessment, staff told us they felt listened by management.

We reviewed evidence confirming concerns and complaints made by people and relatives were recorded and acted upon. People and relatives shared mixed views about the concerns they raised being listened to. Their comments included, "I’ve no complaints up to now. I have a number to contact if needed. I trust the carers;" "I have no complaints about Comfort Care. If I did then I’d talk to the main carer and then the manager at the office" and "They do reply sometimes but not always or they just say ‘we are looking at your concerns’ or ‘your complaint has been upheld’ but no further information." We discussed these concerns with the registered manager and we reviewed evidence confirming this relative's concerns had been investigated and responded to, in line with the provider's complaints procedure. We reviewed evidence confirming concerns and complaints made by people and relatives were recorded and acted upon.

The registered manager told us about the actions they had taken to improve staff's wellbeing, moral and engagement with the service. During our inspection, staff reported feeling well supported by the management team.

The registered manager told us they used the monthly newsletter to share with staff relevant information about the branch, as well as to recognise the work they had done and welcome new staff.

In our conversations with the registered manager, they told us how they kept an oversight of the safety and quality of the service through their regular audits and conversations with staff, people and relatives. However, during this inspection, we found some quality assurance processes had been effective in identifying and addressing issues, but we also found examples were audits had not identified issues found during this inspection.

Quality assurance processes and procedures had not always been effective in identifying and addressing issues with medication, quality of risk assessments, recording of decisions for people who lacked capacity to make specific decisions and restrictions in people's care. We found the provider was supporting the branch by completing regular audits however, these were not always effective. We found issues with care visiting times and durations had been identified before and we continued to find issues in these areas. Care plan audits were not robust. For example, one care plan audit had been completed in March 2024 for a service user, which included care and medication records. The audit showed some issues were found and actions taken. However, during this inspection, we continued to find issues with the service users medication records requiring additional detail to guide staff. People and relatives told us improvements were needed in how the service was managed. Their comments included, "I think it could be managed better from their side. It’s the visit times. I need a reliable routine"; "The main issue is visiting times and carers needing to stay for the full visit;” "The visit times and carers staying longer would be an improvement;” and “Keeping clients up to date, especially on last minute changes if there are delays.” This was a breach in regulation 17 (good governance) because the systems in place were not always operating effectively.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.