Our Commitment to Continuous Improvement at Bespoke Care

At Bespoke Care, we are proud to deliver high-quality, compassionate support to individuals and families across Huddersfield and Kirklees. Providing safe, dignified, and person-centred Personal Care in the community is at the heart of everything we do.

Following our most recent inspection by the Care Quality Commission (CQC), our overall rating has changed from Good to Requires Improvement.

We believe it is important to be open about this, to explain what it means, and to share the actions we have already taken to improve.

Understanding the CQC Rating

The CQC identified that while many aspects of our service continue to meet expected standards, there were areas where our systems and processes required strengthening.

Importantly, the inspection also recognised that:

• People felt safe using our service

• Staff were kind, respectful, and caring

• Care remained person-centred and responsive to individual needs
  

These are values we are proud of and remain fully committed to maintaining.

The areas identified for improvement related primarily to how we manage, monitor, and evidence the quality of our service, rather than the compassion or intent behind the care we provide.

What We Identified

Alongside the CQC inspection, we carried out a full internal Quality Improvement Audit across all areas of the service.

This confirmed that while care delivery remained strong, some of our internal systems were not operating as effectively as they should. In particular:

• Governance systems were not consistently identifying risks

• Oversight processes were not fully structured or embedded

• Some training and compliance systems required strengthening

• Documentation and audit processes needed to be more robust and consistent
  

We recognised that these issues created a gap between the quality of care being delivered and our ability to clearly evidence and monitor that care. What We Have Done

Since the inspection, we have taken immediate and comprehensive action to address these findings.

This has included:

Strengthening Safeguarding and Risk Management

• Introduction of clear escalation guidance for all concerns

• Full audit and review of safeguarding decisions and reporting

• Improved systems to ensure timely escalation and oversight

Improving Governance and Oversight

• Implementation of a structured Quality Improvement Plan (QIP)

• Introduction of regular governance meetings with clear accountability

• Development of a full audit cycle linking findings to action and review

Enhancing Training and Workforce Support

• Full audit of staff training and competency

• Introduction of a structured supervision, observation, and appraisal framework

• Delivery of practical, in-person training for high-risk areas such as moving and handling

Redesigning Care Planning and Documentation

• Introduction of a new care planning framework to improve clarity and consistency

• Separation of care plans and risk assessments to strengthen safety and compliance

• Improved recording standards to support safe, effective care delivery

Strengthening Recruitment and Compliance

• Full review of recruitment records and processes

• Implementation of stricter pre-employment checks and documentation standards

• Ongoing audits to ensure continued compliance

Where We Are Now

We are currently in a period of structured improvement.

There is clear evidence of progress across all areas of the service, including stronger oversight, improved systems, and greater organisational awareness of risk.

However, we also recognise that improvement is not just about making changes, it is about ensuring those changes are consistently applied and sustained over time.

Our focus now is on embedding these systems fully across the organisation, ensuring that high standards are not only achieved but maintained.

Our Ongoing Commitment

As an Award Winning Care provider based in central Huddersfield, we are committed to continuous improvement and transparency.

We welcome the CQC’s feedback as part of our ongoing development and remain focused on:

• Delivering safe, high-quality care in Huddersfield services

• Maintaining dignity, respect, and independence for every individual we support

• Strengthening our systems to ensure consistent, reliable care

• Listening to feedback from service users, families, and staff

Reassurance for Our Service Users and Families

We understand that any change in rating can be concerning.

We want to reassure all of our service users and their families that:

• Care continues to be delivered safely and compassionately

• Our staff remain dedicated, skilled, and committed

• Significant improvements have already been made

• We are actively monitoring and strengthening our service every day

Looking Ahead

This period of improvement represents an important step forward for our organisation.

We are confident that the actions we have taken, combined with our ongoing commitment to quality and accountability, will ensure continued progress and a return to a higher rating in future inspections.

At Bespoke Care, our priority remains unchanged, providing reliable, person-centred care that supports people to live safely and independently in their own homes.

CQC Improvment Plan Full.docx

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