Compassionate Herts Ltd, a small domiciliary care service supporting five people in Hemel Hempstead, was rated Good overall following a November 2023 inspection of the Safe and Well-led key questions. No failure themes were identified; the Well-led rating improved from Requires Improvement to Good, reflecting strengthened quality assurance systems and person-centred leadership.
Strengths
· Staff completed safeguarding training with annual refreshers and knowledge checks; safeguarding was a regular staff meeting agenda item.
· Safe recruitment processes in place including DBS checks, two validated references, and exploration of employment history gaps.
· Medicines administered at prescribed times by trained staff with competency checks; MAR records reviewed monthly with no errors recorded.
· Registered manager established robust quality assurance including spot checks, audits, telephone and face-to-face visits, and surveys.
· Person-centred care plans co-produced with people; carers matched to people from similar ethnic and cultural backgrounds where possible.
Quality-Statement breakdown (12)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
well-led: Continuous learning and improving careGood
Compassionate Herts Ltd was rated Good overall following an announced inspection in January–February 2018, having addressed previous breaches relating to recruitment, governance and fit and proper persons. The sole area requiring improvement was record keeping, including insufficiently structured staff support records and incompletely documented recruitment checks.
Concerns (3)
moderateRecord keeping: “recruitment records in some cases lacked detail and were not as robust as they could have been. Staff support records lacked structure.”
moderateGovernance: “Quality monitoring audits were in place but would benefit from further development to ensure actions were signed off to improve the effectiveness.”
minorRecord keeping: “records were kept in relation to staff support arrangements. These were not structured and did not have an agenda, objectives or clear outcomes.”
Strengths
· People felt safe and staff were knowledgeable about risks and signs of abuse
· Sufficient staffing levels with adequate travel time planned between visits
· Staff supported people to take medicines safely with competency checks at regular intervals
· Staff received regular supervision, work-based observations and relevant training
· Registered manager demonstrated good awareness of Mental Capacity Act principles
Compassionate Herts Ltd received an overall rating of Requires Improvement at its first inspection in July 2017, with three regulatory breaches identified covering safeguarding training, fit and proper persons employed, and good governance. Strengths were noted in caring and responsive domains, with staff described as kind and reliable by people using the service and their relatives.
Concerns (8)
criticalSafeguarding: “Staff had not received safeguarding training and did not fully understand their responsibility to protect people from harm.”
criticalStaff training: “Staff had not had an induction when they started work at the service... staff had only completed three training sessions during their employment.”
criticalGovernance: “The provider did not have effective quality assurance processes in place to monitor the service. This was a breach of Regulation 17 HSCA RA Regulations 2014”
criticalStaff competency: “The recruitment process was not robust. pre-employment checks were not consistently completed in accordance with the provider's own recruitment process.”
criticalConsent / capacity: “People's mental capacity was not assessed in accordance the Mental Capacity Act (MCA) 2005... two people who lacked capacity had not had their capacity assessed.”
moderateRecord keeping: “Records such as care plans and risk assessments were not always dated or signed so we could not be assured they were current.”
moderateSupervision / appraisal: “Staff received some support and one to one supervision. However... supervision was ad hoc and did not detail a comprehensive record of discussion points.”
minorCare planning: “Care plans were kept under regular review. However this was not currently being recorded.”
Strengths
· People were treated with dignity and respect by staff who knew them well and had developed meaningful relationships.
· People gave positive feedback about staff being kind, caring and reliable.
· Complaints were recorded, investigated and responded to appropriately.
· People were supported to access a range of healthcare professionals.
· People were supported to eat and drink sufficient amounts.
Quality-Statement breakdown (15)
safe: Recruitment and pre-employment checksRequires improvement