Comforting Healthcare

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 requires improvement. At this assessment the rating has remained requires improvement. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was in breach of legal regulation in relation to the governance at the service.

This service scored 57 (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 service and staff had a good understanding of the people they supported and were backed by a consistent team. Staff told us they delivered person-centred care and worked closely with other professionals. Regular team meetings were held to keep staff informed about changes within the service. A staff member said, “We have team meetings where we discuss what we can change or improve for people.”

The service 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.

The management team demonstrated an inclusive and compassionate approach toward both the people they supported and their staff. Staff described the leadership as open and honest. One staff member commented, “We go above and beyond; the service feels like a family hub. We’re doing a job, but it feels like being part of a family.”

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 they would speak to the service about any concerns and felt comfortable doing so. Staff told us they could speak to management about concerns, and they would be listened to. A staff member said, “Yes, you can raise anything and feel listened to.”

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. Staff felt they were treated fairly and equally.

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.

Governance systems were not functioning effectively, which meant the service lacked adequate oversight and failed to identify the shortfalls highlighted during this inspection. For example, processes relating to medicines management, risk assessments, and Mental Capacity Act (MCA) documentation were not always accurately recorded or completed. There were no robust systems in place to assess, monitor, and improve the quality and safety of the service. Additionally, staff training was not consistently current, which meant their knowledge was not always up to date.

The registered manager explained that a new audit system had only been introduced in November 2025. They acknowledged that the current audits were not effective in identifying areas for improvement and confirmed plans to redesign them. The management team were transparent and receptive to our findings throughout the assessment and undertook action to make improvements. The provider acknowledged the existing systems and processes needed strengthening.

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. There were systems in place to ensure the provider worked in partnership with other agencies.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Opportunities to drive improvements within the service had been missed as quality assurance processes and systems were not effective. Following our feedback, they told us they would create an action plan to include the areas of concern we identified during the inspection.