Compassion Care Limited

The assessment was undertaken due to the length of time since the previous assessment. This was an off-site assessment, which meant all requested records were submitted electronically and reviewed remotely. The provider was given 72 hours' notice of the assessment to ensure management staff were available to support the process and provide the information requested.

The service was not consistently well-led. There was not a registered manager in post at the time of this assessment, there was an acting manager in post who had started June 2026. There were significant concerns regarding the safety, effectiveness and governance of the service. Medicines were not always managed safely, care plans and risk assessments were not always accurate, complete or regularly reviewed, and the provider could not always demonstrate that people's needs were assessed and managed using evidence-based practice. Where people were deemed to lack capacity, the provider had not always followed the principles of the Mental Capacity Act 2005.

Governance systems were not effective in identifying and addressing concerns in a timely way. Audits had not consistently identified areas requiring improvement, there was no effective system for capturing and sharing lessons learned, and the provider could not always demonstrate that incidents, accidents, complaints and safeguarding concerns were appropriately recorded, monitored or analysed. Records did not always contain accurate and up-to-date information, which could impact the safe delivery of care and the sharing of information with other professionals when required. Staff also raised concerns about leadership, support and fairness within the organisation.

The acting manager had introduced initiatives to support staff wellbeing. Staff were committed to providing good quality care and there were examples of positive partnership working. However, systems and processes were not yet sufficiently embedded to ensure consistent oversight, safe care and continuous improvement across the service.

Staff knew people well and people told us they were supported by kind, caring and compassionate staff who treated them with dignity and respect. People were involved in decisions about their care and were generally supported to maintain their independence, choice and control.

Overall, we found people were supported by caring staff, but improvements were needed to ensure safe, effective and well-led care, with stronger governance arrangements, better record keeping, clearer risk management and greater assurance that people consistently received care that met their needs.

The provider was in breach of the legal regulation relating to safe care and treatment, consent to care and good governance. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.