Compassion First Care Ltd improved from Requires Improvement to Good overall at this December 2022 inspection, with safe, effective, caring and responsive domains all rated Good. Well-led remains Requires Improvement due to continued failure to notify CQC of safeguarding referrals and quality assurance systems not consistently identifying and evidencing corrective actions.
Concerns (4)
critical
Governance
: “2 safeguarding notifications had not been sent to us. We raised this with the registered manager who took action to send these notifications retrospectively to us.”
criticalSafeguarding: “The registered manager had not notified CQC as required of all safeguarding referrals they had made.”
moderateGovernance: “Quality assurance tools had not always identified areas of improvement which were required around people's cream records and staff travel times.”
moderateRecord keeping: “Where audits had identified areas of improvement were required, actions to address these required improved were not recorded to evidence these improvements had been made.”
Strengths
· People supported by consistent staff who knew them well and attended calls on time without making people feel rushed.
· Medicines managed safely with clear as-required protocols in place.
· Effective risk assessments in place including improvements to choking risk guidance since last inspection.
· Staff trained in safeguarding, infection control, MCA and relevant care skills.
· People and relatives highly positive about staff kindness, consistency and the registered manager.
Quality-Statement breakdown (23)
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
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 staffGood