Quality & Compassion Ltd

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 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 3 legal regulations in relation to governance at the service, notifying the Commission of certain events and updating the Commission on changes made to the provider’s statement of purpose.
 

This service scored 54 (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. This was based on equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were aware of the vision and values of the provider, and it was clearly communicated through Quality Compassion Ltd website. The provider stated, “everyone should have the opportunity to live a healthy, active and fulfilling life.” We found examples of how staff supported people, which included supporting them with weight loss, encouraging independence and increasing people’s confidence.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The provider had failed to ensure sustained improvements were made following our last inspection. We found continued breaches of legislation, which had the potential to put people at increased risk of harm.

The registered manager had failed to ensure care and support was being delivered in line with the provider’s own policies and procedures and best practice guidance.

Poor management oversight created risks to people using the service.
 

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

People and relatives told us they felt they could speak with the care co-ordinator and registered manager. One relative told us, “[care coordinator] is fantastic, I can’t fault them”.

Staff were aware of the term ‘freedom to speak up’ and told us, “To me, freedom to speak up means staff can raise concerns, ideas, or issues without fear of being ignored or treated unfairly. It helps create a safe and positive working environment” and “I understand the term ‘freedom to speak up’ as feeling safe for me to raise concerns about client’s safety or workplace issues”.

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 told us they were fairly treated at work. Comments included, “I feel staff are treated fairly and respectfully. Everyone is expected to work professionally, and concerns can be raised if someone feels unsupported or treated unfairly” and “I feel I am treated fairly and equitably”. Staff told us they benefitted from weekly “Wednesday class training and discussions on issues raised by carers” which helped staff feel included and supported.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

The provider had a quality assurance system in place; however, this had failed to identify and/or rectify the concerns found at previous inspections and this assessment. Not all areas of the service were monitored for quality and to drive improvement. Where quality monitoring audits were in place, these did not provide assurances they were robust and meaningful.

The provider and registered manager failed to demonstrate they had the required knowledge in relation to their regulatory responsibilities; we found continued breaches of legal regulations, which had the potential to increase harm and risks to people. In addition, at this assessment we identified 2 new breaches of the legal regulations. The provider had failed to ensure they notified us of all the events and changes they were legally required to do so. This included telling us about safeguarding concerns raised with the local authority as an example.

People’s records were not always representative of the individual. For instance, we found inconsistencies in people’s care plans. Care plans contained contradictions which could have led to harm. Mental capacity assessments were not completed in line with the MCA or associated code of practice. Risks were not always assessed and mitigated which increased the likelihood of harm to people.
 

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.

The registered manager told us, “Our service demonstrated effective partnership working with [local authority], family members, and a new care provider to ensure a safe and smooth transition of care following the handover of the care package.” This was supported by feedback from the local authority, who wrote to the provider to say “We would like to acknowledge the effective partnership working throughout this process. The transition has been well managed and seamless for our service users.”
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

There was no effective system in place to measure and evaluate the service. The provider failed to ensure outcomes were consistently positive and safe and all reasonable steps had been taken to mitigate risk.

We found the provider had not ensured improvements had been made and sustained since our last inspection. We found continued breaches of legal regulations at this assessment which had the potential to increase risk of harm to people. In addition, we identified 2 more breaches of the legal regulations. This highlighted the provider’s lack of improvement culture.