Compassion Home 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 inadequate. At this assessment the rating has improved to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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.

All the people, their relatives, staff and other healthcare professionals we spoke with said the service was very well led and that there had been a transformation in every aspect of the provider’s leadership since the last inspection. Staff demonstrated they were committed to this and they promoted the values and principles of Compassion Care. There was a positive culture within the service, staff were friendly and welcoming and were open about the support they offered to people and the barriers they faced.

The provider 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager demonstrated they had the skills and knowledge to manage the service effectively. Feedback from people and staff confirmed this. Comments we received included, “I find management to be highly professional with good standards of care, supervision and support for staff,” and “The managers and staff are very approachable, if there is any issue, it is addressed.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Processes were in place for staff and people to speak up. The provider had a clear whistle blowing policy. Regular feedback surveys were carried out, analysed with action plans put in place for any improvements necessary. Staff could raise concerns and the information about how to do this was available in the staff handbook. Regular staff meetings took place. Staff told us they felt valued and supported by the management team. They were encouraged to voice their opinions, ideas and suggestions. Staff comments included, “We have regular staff meetings and can make any suggestions, we are 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.

The provider ensured there were effective and proactive ways to engage with and include staff. Regular quality calls took place enabling care staff to have direct engagement with the managers. Staff said they felt empowered and were confident that their concerns and ideas would be listened to and would result in positive change to shape services. Staff described the organisation as supportive and told us they felt valued working there.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The providers quality assurance systems were comprehensive covering every aspect of service delivery. We saw it was effective at identifying shortfalls and risk. Quality audits were completed to ensure safe care delivery and action was taken to ensure safety incidents were responded to. Provider level audits and checks took place to provide an additional layer of quality assurance and ensure regulatory compliance. We found many examples of where these had been effective. In one case, the provider audit had prompted the registered manager to ensure a staff competency interview had been completed following an incident.

Service communication was excellent. Staff were well informed of organisational and localised changes to the service. Feedback from people also supported this understanding, stating they were kept up to date of changes and could always reach the office if they needed anything. Leaders were also available when staff needed support including out of hours.

The provider described their plans for future development and sustainability. This included further integration of the new digital systems already in place.

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.

Staff worked in a coordinated way with other professionals to ensure appropriate and coordinated support was provided for people. Health care professionals told us that Compassion Care worked with them to deliver the best possible coordinated care for the people they all supported. People and their families also confirmed this when talking about the joined-up way health and social care providers worked to support them.

Comments included, “We work very well together with the staff team and managers at Compassion Care,” “It is evident from the joined-up approach we all take with the team at Compassion Care how people can benefit from this approach. It is an excellent example of integrated therapy and optimisation of quality of life for people receiving this service.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had effective procedures in place regarding reporting and learning from when things went wrong. The registered manager told us [and we saw evidence to support this] that they carried out regular checks of the quality and safety of people's care. This included checks of the environment and equipment used for people's care and checks of medicines and care plans.

Regular checks were made of any accidents. They were also carried out for people's health and nutritional status and any related incidents, such as weight loss, infection or skin sores. This helped to identify any trends or patterns to inform any changes that may be needed to improve people's care.

The service’s development plans included actions that came from these audits, quality assurance processes and feedback. All action points had a target completion date and identified the staff member responsible for them. We noted this system had been effective in driving improvements, such as improving the mealtime experience.