Comforting Healthcare

The provider was in breach of the legal regulation relating to good governance.

The service demonstrated a positive safety culture, underpinned by systems designed to report, investigate, and learn from incidents, although no incidents had occurred since operations began. Risk assessments were generally detailed and person-centred; however, there were gaps, including unclear guidance for choking risk and missing epilepsy risk assessments. These were addressed following feedback. Safe environments were maintained through home safety checks and equipment training. Staffing levels were sufficient, but some people experienced late or rushed visits, and gaps in staff training persisted despite measures to improve compliance. Medicines management required improvement, as Medication administration records were inconsistently completed and instructions for topical medications were unclear, though no harm occurred.

Care was delivered effectively, with assessments completed before care commenced and reviewed when needs changed. Care planning aligned with legislation and evidence-based practice, and staff demonstrated appropriate skills and knowledge. The service worked collaboratively with external professionals to ensure continuity of care and reduce duplication forpeople. People were supported to live healthier lives and maintain independence, although the quality of care records varied, with some lacking detail about conditions and preferences. Consent practices required improvement; while staff understood the importance of consent, decision-specific capacity assessments were not always completed when concerns arose. This was addressed promptly following feedback.

People consistently experienced care that was kind, compassionate, and respectful. Staff maintained privacy and dignity and demonstrated empathy and familiarity with individuals’ needs and preferences. Care was delivered by a regular, consistent team, which helped build trust and positive relationships. People were treated as individuals, with care plans reflecting personal histories, cultural needs, and preferences. Staff promoted independence, offering choices and encouraging people to maintain control over their care. Workforce wellbeing was prioritised, and staff reported strong support from the registered manager and felt able to raise concerns.

The service generally met people’s needs through good organisation and delivery, but some shortfalls were identified. Care was not always fully person-centred, as some care plans were incomplete or contained outdated information, particularly around medication and long-term conditions. The provider worked with other professionals to ensure care was well-coordinated, and information was shared in accessible formats. People were encouraged to provide feedback and raise complaints, and most felt confident concerns would be addressed, although one relative expressed dissatisfaction with follow-up on late visits. Equality and access were promoted, but staff had not completed equality and diversity training. Planning for future care, including end-of-life preferences, was limited, as individual plans were not in place.

The service had a shared vision and culture based on transparency, equality, and inclusion, and leaders were described as compassionate and approachable. Staff felt supported, valued, and able to speak up, with regular team meetings promoting communication and engagement. However, governance systems were weak and did not provide effective oversight. Processes for medicines management, risk assessments, and Mental Capacity Act documentation were not consistently accurate or complete, and quality assurance systems were ineffective. Staff training was not consistently up to date, and opportunities for learning and innovation were missed. A new audit system had only recently been introduced, and leaders acknowledged the need for improvement, demonstrating openness and commitment to addressing these issues.