Chasfab Options Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture as people’s equality and human rights, diversity and inclusion was not central to their care provision. Staff told us they worked well with the management team, and colleagues worked well together to support people. However, at the time of the inspection, staff meetings between staff and management were infrequent, and quality audits did not pick up on some of the issues we found at the inspection.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders had access to training in how to support people with their care needs. However, they did not demonstrate skills, knowledge, experience and credibility to lead effectively. Leaders did not not demonstrate skills, knowledge, experience and credibility to lead effectively. As part of the assessment, we looked at the training staff had received while employed by the service. We were initially told the only training staff had completed was 14 mandatory training sessions it was documented staff had attended on 4th and 5th October 2024 while rota’d so support people on these days. We had to gather information from a 3rd party to support staff had received training in the more complex areas of support such as gastronomical and diabetes care. The onus is on the registered manager to have full and accurate records in relation to this. We were later advised the only records of staff receiving training in relation to complex care and support of people held by the service was by way of calendar invites informing the dates the training events were held. The service did not demonstrate robust planning or appropriate assessment of risk. Some care plans lacked information about people’s equality and diversity, so people were at risk of being supported by a registered manager and staff who were not fully aware of how to support them with these needs. Audits completed by the registered manager did not identify or address concerns we found with recruitment documents, medicines management, training and the lack of medical risk assessments and concerns found with recruitment records. This put people at the risk of avoidable harm.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A member of staff told us, “The management team always respond upon any issues immediately.” A relative told us, "I have direct and easy access to the [registered manager] whenever I need to discuss [relative's] care needs. [Registered manager] regularly checks in with us to ensure everything is going smoothly."

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had equality, diversity and inclusion policies in place. Staff told us they were treated fairly and had no concerns about their own treatment and to their knowledge the treatment of their colleagues.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.People's relatives and staff told us the registered manager carried out spot checks to ensure care was being safely delivered. However, we found checks and audits did not identify concerns we found in relation to staffing records, medicines records and care plans and lack of risk assessment. For example, we viewed an audit report dated June 2024, which stated all care plans had been audited, and all information was accurate and up to date. However, at the inspection, we found a care plan which the persons date of birth input incorrectly, and another care plan which had no GP details added and incorrect details around their needs and wishes. We also found concerns around staff recruitment and training which had not been identified by the provider’s governance systems. Poor management oversight left people at the risk of poor care and support.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Health care professional said, "I particularly appreciate their attention to detail and their willingness to collaborate, which has contributed significantly to the success of our working relationship. Overall, I have been very satisfied with the service provided by Chasfab Options Limited."

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. The provider had a good working relationship with healthcare professionals. However, minutes of meetings did not support robust discussions around reviews, concerns or lessons learned from things that may have or could potentially go wrong. The provider showed us evidence to support all staff received their mandatory training at the same time over a period of 2 days, despite some staff beginning their employment almost a year earlier than others. Staff completed training while rota’d to complete care visits. One relative told us, “The registered manager will do spot checks, and checks to ensure [staff] have completed their online training.” This indicated staff were not able to prioritise time to develop their skills or complete their training as required outside of delivering care and support to people.