Quality & Compassion Ltd

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 inadequate. 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 continued breach of 3 legal regulations in relation to people’s safe care and treatment, staffing and recruitment.

This service scored 44 (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 did not always have a proactive and positive culture of safety based on openness and honesty. The provider had some systems in place to learn from events and gain feedback from people, staff and stakeholders. However, opportunities to learn from incidents, feedback, and audits were not always maximised. For instance, we found ongoing concerns about the management of risk.

We found the provider had not fully acted upon our previous feedback to ensure improvements were embedded and people always received safe care and treatment. For example, we found continued breaches of all 5 regulations from when we last assessed the provider in 2023. This showed lessons and not always been learnt from or action taken to make improvements.

The registered manager had commenced weekly learning sessions for staff. These had been in place since last year. We observed a meeting whilst we were onsite. Feedback from staff confirmed the meetings were useful. Comments from staff included, “Staff meet every Wednesday to discuss concerns, share learning experiences, and raise any difficulties encountered during the week", "These meetings help staff stay informed, supported, and updated on any changes or important matters within the company” and “Lessons learned from incidents are shared through our Wednesday learning sessions.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We received mixed feedback from people and their relatives about how the service supported people to attend medical appointments. One person told us, “I have missed about 3 appointments… they say they don’t know anything about it.” However, another person told us, “I will ask them to call the GP or district nurse and they do that for me.”

Staff had information available to them on how to support people if they needed a hospital admission. One member of staff told us “If the state of deterioration is life threatening, I will call emergency service 999 for an ambulance immediately. If it is not life threatening, I will call GP or 111 to speak with clinical advisor.”

We have spoken with the registered manager to ensure people feel listened to about their healthcare needs and any support they need to attend appointments.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider did share concerns quickly and appropriately.

People told us they felt safe with staff supporting them. One person told us, “Yes, I feel safe…” This was supported by what relatives told us. One relative told us, “[person] doesn't seem to be uneasy with them” and “[staff] are never unkind”.

We found the provider had reported safeguarding concerns to the local authority when they had been made aware of concerns. The provider had a safeguarding policy in place, which followed best practice guidance. Not all staff had received training on how to recognise and report safeguarding concerns. However, those who had told us, “I feel confident raising safeguarding or abuse concerns because protecting individuals is very important”, “I feel supported to report concerns without fear of blame” and “It is my professional duty and responsibility to report any signs of abuse or concerns that I may observe.”

The Mental Capacity Act 2005 (MCA) provides the legal framework which protects people who lack capacity while ensuring their rights are respected. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. Quality Compassion Ltd were not supporting any person who had a Court of Protection deprivation order.We found people who had restrictive practices in place did not routinely have these assessed under the MCA

The provider did not work well with people to understand and manage risks. People were placed at risk of harm due to the lack of effective and robust risk management.

We found the provider failed to ensure risks posed to people and staff were fully assessed and mitigated. This placed people at risk of avoidable harm. For example, where moving and handling risk assessments were in place, these did not fully explore how a person should be supported or what type of equipment was needed. Some people who required support with moving positions did not have any risk assessments in place. In addition, not all people who used equipment to help them maintain their safety had risk assessments in place to advise staff on how to prevent harm. For example, one person used bed rails to keep them safe in bed and no risk assessment was in place.

People who were diagnosed with diabetes did not always have care plans or risk assessments in place to give staff information on symptoms which may indicate the person’s diabetes was unstable and therefore making them unwell, and the actions they needed to take in response. This placed people at risk of harm.

People who were diagnosed with epilepsy, or who were prescribed anti-seizure medicine, did not have detailed care plan and risk assessment in place to advise staff on how they should identify if the person was experiencing a seizure, and what action to take. This placed people at risk of harm.

We found the provider had failed to identify risks to the health and safety of people and do all that was reasonably practicable to mitigate any such risk to prevent or reduce avoidable harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found the provider had completed environmental risk assessments for people they supported, however these routinely failed to identify all potential risks. For instance, one person was prescribed oxygen, and this had not been fully considered. This had the potential to put the person and staff at risk of harm. We found fire risk assessment routinely failed to mention flammable medicines prescribed.
 

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People were not supported by staff who had been safely recruited and supported in their role. We found significant concerns in relation to the providers recruitment, training and support systems for staff to ensure they could meet people’s care and treatment needs.

The provider failed to ensure they always operated safe recruitment practices, and they did not have robust systems in place to monitor these. We observed conflicting information in application forms related to staff health. This had not been identified or followed up by the provider. This meant staff were not always supported in line with equality legislation and the provider had not ensured the staff were safe to work with people.

We found staff had not received sufficient, appropriate training and competency checks to ensure they delivered safe care and treatment. Training was not provided regularly in line with the provider’s policies or national guidance on good practice. Assessments to determine staff competency had not been signed off by people trained to do so. We discussed this with the provider and requested immediate action to ensure staff were suitably trained. The provider responded swiftly to this request and took steps to rectify this.

We observed staff had not been provided with regular 1 to 1 meetings with a line manager (supervisions) and annual appraisal of their performance. The provider was unable to demonstrate staff had undergone a robust induction and shadowing process, as stated in the provider’s policy. This meant the provider was unable to assure themselves people were receiving safe and good quality care from staff who were equipped to do so.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We received mixed feedback from people and their relatives about how staff kept them safe from infections. One relative told us the staff supporting their relative did not change protective gloves between providing personal care and supporting the person with meals. This is against best practice guidance and the provider’s own infection, prevention and control policy dated February 2026. This had the potential to cause harm to people. However, other people and relatives told us they felt the risk of infection was managed well. One person told us, “They [staff] all seem to manage that”, when referring to staff supporting them with a particular condition. We discussed our concerns about how staff use personal protective equipment (PPE) for the provider to take action, to ensure infection risks are better managed.

Staff who supported people had received training in infection control and food safety.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People who were prescribed medicines which had the potential to cause internal and external bleeding did not have risk assessments in place to advise staff on how they should monitor the person for any bleeding.

People who used emollients or other flammable medicines did not have care plans and risk assessments in place to alert staff on how to prevent harm due to fire or burning.

However, people and relatives told us they were happy with how staff supported them with their medicines. One person told us, “I feel down and some days I am alright, it is the way they approach me (to support with medicines). I know I have to take my tablets but they [staff] don’t force me. It is the way they go about it; they nudge me.” Not every supported by Quality Compassion Ltd required staff to support them with medicines

Guidance was in place where people were prescribed medicines for occasional use. This helped staff to give these medicines in a consistent way. Medicine administration records (MARs) we looked at demonstrated staff supported people when needed.

Staff told us they were confident in supporting people with their medicine. Comments from staff included, “I make sure the right person receives the right medicine at the right time and record it correctly. I also report any concerns or side effects to my coordinator”, “I do support the individual with medication based on their care plans by checking the medication administration records carefully” and “One client prescribed tablets for high blood pressure. I helped by administering them on time and documenting accurately and monitoring the client’s wellbeing.”