Compassion Care 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to people’s safe care and treatment and consent to care.

This service scored 53 (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 could not investigate and report from safety events because systems and process were not in place to do this. This meant lessons were not always learnt to continually identify and embed good practice. For example, we found there was no log of incidents, accidents or complaints prior to June 2026. This meant the provider could not demonstrate that all events had been appropriately reviewed, investigated or analysed to identify trends, lessons learnt and actions needed to reduce the risk of recurrence. As a result, opportunities to improve the safety and quality of the service may have been missed.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always effectively manage or monitor people’s safety and did not always ensure continuity of care, including when people moved between services. For example, initial assessments had been completed before people started using the service; however, we found these assessments were often incomplete and lacked sufficient detail. This meant staff did not always have clear guidance about people’s needs, risks, preferences and how they wished to be supported. In addition, where information needed to be shared with other professionals, such as emergency health services, records did not always contain accurate or complete information. This increased the risk that healthcare professionals may not have access to the information required to make informed decisions and provide safe, effective care. As a result, there was a risk that care may not be delivered consistently or in line with people’s individual needs and preferences.

We were not assured people were protected from abuse and avoidable harm because safeguarding systems were ineffective. There was no robust process to record, review and monitor safeguarding concerns, and we were not assured all safeguarding incidents had been appropriately reported to external agencies, including the local authority and CQC. This meant opportunities to identify risk, take timely action and prevent further harm may have been missed. The provider had a safeguarding policy in place; however, only 52% of staff had completed safeguarding training.

The provider did not always follow the principles of the Mental Capacity Act 2005 when supporting people who were deemed to lack capacity to make decisions about their care and treatment. Capacity assessments and best interest decisions had not been completed where people were assessed as lacking capacity. This meant the provider could not demonstrate people’s rights were being protected or that decisions were made lawfully and in their best interests. This meant people were at risk of receiving care and support that did not fully reflect their wishes, needs or legal rights.

The provider did not always ensure staff supported people safely. We found staff did not have clear guidance in place to ensure people were supported in a safe way and according to their needs. For example, a person who required support with their mobility needs had inaccurate and contradicting information in their care plan. The lack of risk assessments and care plans meant staff had no guidance or inaccurate guidance to ensure they could support people safely.

The provider did not always detect and control potential risks in the care environment. They did not always ensure equipment, facilities and technology supported the delivery of safe care. For example, one person's care plan recorded the next hoist service date; however, there was no evidence the service had been completed or that checks had been undertaken to confirm the hoist remained safe to use. This meant the provider could not be assured equipment was properly maintained and safe, placing people at potential risk of harm.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. For example, Staff had not always completed training relevant to the needs of the people they supported. Training records showed gaps in both the provider’s mandatory and specialist training. For example, not all staff had completed training in diabetes, Parkinson's disease, and oxygen therapy, despite supporting people with these conditions. In addition, only 14% of staff had completed equality and diversity training, and 52% had completed safeguarding training. These gaps meant staff did not always have the necessary knowledge, skills, and competencies to meet people's individual needs safely and effectively, or that all staff were appropriately trained to recognise and respond to safeguarding concerns.

Staff had been recruited safely and staff told us they had completed an induction, one staff member said, “I went through induction and shadowing sessions.”

The provider had an infection prevention and control policy in place, and most staff had completed the required training. Spot checks were undertaken to monitor staff practice and ensure they followed infection prevention and control procedures and guidance.

The provider did not always ensure medicines and treatments were managed safely and met people’s needs, capacities and preferences. We found people were not always involved in planning their support with medicines. Where staff supported people with their medicines, there was not always a care plan or risk assessment in place. In addition, staff did not always have clear guidance for medicines prescribed with variable doses, such as when to administer one or two tablets, and topical medicines did not always include instructions on where they should be applied. This meant staff may not have had sufficient information to administer medicines safely and consistently, placing people at risk of harm.