Quality & Compassion Ltd

The provider was previously in breach of 5 legal regulations in relation to safe care and treatment, consent, staffing, recruitment, and good governance. We took enforcement action under safe care and treatment. We issued a warning notice to the provider to ensure improvements would be made. This assessment was planned to check improvements had been made and if the enforcement action had been met. We found the enforcement action had not been met and the provider remained in breach of regulations.

We found the provider was in continued breach of all 5 legal regulations, in safe care and treatment, consent, staffing, recruitment and good governance. We identified 2 new breaches of regulation in relation to notifying the Commission of certain events and changes made to the provider’s statement of purpose.

The provider failed to ensure all risks to people had been identified and mitigated, where risks had been identified, the management of them was poor. We found similar concerns about risk management at this assessment as we had at the last inspection. This highlighted the failure of the provider to make sustained improvements.

The provider demonstrated a lack of understanding and application of the Mental Capacity Act 2005. We found capacity assessments were poorly completed and failed to record any best interest process.

Staff supporting people with complex needs had not received appropriate training in line with nationally recognised timeframes, or had their competency checked to ensure they could provide safe care.

The provider was not able to demonstrate safe recruitment practices. We found application forms were missing or poorly completed, a lack of interview records to clearly evidence the staff member was the best candidate and health conditions disclosed had not been fully explored to ensure the staff members were supported in their role, or were safe to work with people.

Care plan records were not always accurate; they contained out of date information or contradictory information was recorded.

The provider’s governance system was not robust enough and failed to identify the shortfalls found at this assessment. For example, the provider’s policies clearly provided a timeframe and description of planned quality audits. However, these had not been completed as planned.

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

People who had a learning disability were supported by staff who encouraged their independence. People were supported to make choices about meals and be involved in decisions about their care.

We have asked the provider for an action plan in response to some of the concerns found at this assessment.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.