Compassion Care 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvements. 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 service was in breach of legal regulation in relation to good governance at the service.

This service scored 50 (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; however, these were not embedded in practice. There were no effective systems or processes in place to ensure people consistently received care in line with the provider’s values and expectations. Governance and oversight arrangements were ineffective, and leaders had not identified or addressed the concerns found during this assessment. This meant the provider could not be assured that people were receiving safe, effective and high-quality care in line with the service’s stated vision and objectives.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The service was not well-led by the provider. There were ineffective systems and processes in place to provide staff and leaders with accurate oversight of the service. The provider had not completed effective audits, checks or reviews and had therefore missed opportunities to identify and address shortfalls in a timely way. As a result, leaders did not always have sufficient oversight of the quality and safety of the service.

Staff did not always feel supported by the provider. One staff member told us, “My experience with the wider senior management team has been less positive. Whilst they are approachable, I do not feel they have sufficient visibility or understanding of the day-to-day operation of the service, our clients, or the systems we use.” Staff described difficulties resolving concerns, delays in decision-making and a lack of clear outcomes when issues were escalated. This indicated leaders were not always visible, knowledgeable or effective in supporting staff and driving improvement.

The lack of effective governance systems meant the provider had not identified concerns we found during the assessment, including issues relating to care planning, medicines management, staff training, safeguarding and the monitoring of incidents and complaints. This demonstrated leaders had not consistently assured themselves the service was operating safely, effectively and in line with regulatory requirements. As a result, people were at risk of receiving care from a service where quality assurance and oversight arrangements were ineffective.

Whilst we received positive feedback regarding the acting manager. Staff did not always feel they could speak up and that their voice would be heard by the provider. One staff member told us, “There have been wider concerns raised in meetings. However, from my perspective, many of these concerns have not resulted in meaningful action or resolution.” Another staff member told us, “The management is always ready to attack when you raise a concern then eventually listen when you put things in writing by sending emails.”

The provider did not always promote an inclusive and fair culture. During the assessment, staff raised concerns about how employees on sponsored work visas were treated, including concerns relating to pay and employment practices. Although the provider had policies in place, they had not identified or addressed these concerns. This meant we could not be assured all staff were treated equitably and with respect. We had reported this concern to the relevant authorities.

The provider did not always have clear responsibilities, roles, 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.

There was no registered manager in post at the time of the inspection. A new manager had commenced employment in May 2026 and demonstrated experience and knowledge of the health and social care sector. However, they had not received a formal induction or training specific to the provider's systems, policies, and procedures.

Governance systems were not always effective in identifying shortfalls and driving timely improvement. Although audits had been completed, identified concerns had not always been addressed or acted upon. For example, a care plan audit completed in July 2026 rated the service as red and identified that care plans lacked sufficient detail and quality. Despite this, we continued to find widespread concerns during the assessment relating to the accuracy, completeness and effectiveness of care plans. This demonstrated that quality assurance systems were not robust enough to address known issues in a timely manner.

The provider did not always demonstrate an understanding of their duty to collaborate and work in partnership to ensure services worked seamlessly for people. Due to ineffective and non-embedded systems and processes, we were not assured that all reportable incidents had been identified and reported to relevant external agencies, including CQC, when required. This meant opportunities to share information, promote learning and ensure appropriate oversight may have been missed.

The provider did not always have systems and processes in place to provide them with oversight of the service to identify areas of required improvement. There was no effective system in place to capture, review and share lessons learned when things had gone wrong. The provider was unable to demonstrate how learning from incidents, accidents, complaints, safeguarding concerns and other events was analysed and used to drive improvements in the quality and safety of the service. Records to support oversight were incomplete, and there was limited evidence of trend analysis or actions taken in response to concerns. This meant opportunities to identify themes, reduce risks and prevent reoccurrence may have been missed. As a result, the provider could not be assured they were consistently learning from events or embedding improvements to promote safe, high-quality care.