CSM Care Services LTD

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We found the provider was in breach of the legal regulation relating to safe care and treatment.

This service scored 59 (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 promoted a positive culture of safety based on openness and honesty. Leaders investigated incidents, complaints and safeguarding concerns and identified learning relating to recognising deterioration, escalation, medicines management, professional boundaries and statutory reporting. Learning was shared with staff through team meetings, supervision, training, competency assessments and updates to people’s care documentation. Leaders were open and responsive during the assessment, reflected on the concerns raised and took action to improve systems and staff practice.

The provider did not always maintain safe systems of care or ensure information about people's changing needs was consistently transferred between records. Staff worked with healthcare professionals and records showed concerns were escalated when required. However, in some records information documented in daily notes and advice from healthcare professionals had not been transferred into the person's care plan or relevant risk documentation. Although the provider demonstrated that staff could also access information through electronic care records and other communication systems, information about people's changing needs was not always recorded consistently across care records and supporting documentation, increasing the risk that important information may not be reflected in all records used to support care delivery.

The provider did not always share safeguarding concerns and notifiable incidents promptly with the appropriate organisations. People and relatives generally said they felt safe, and staff understood how to recognise and report safeguarding concerns. The provider investigated incidents and could demonstrate examples of working with safeguarding professionals. However, some safeguarding matters and statutory notifications had not been submitted at the required time. Leaders acknowledged the shortfalls, made retrospective submissions and took action to strengthen oversight of future reporting.

The provider did not always ensure information about risks to people was consistently reflected across care records and supported by sufficiently clear guidance for staff. Staff knew people well and described appropriate action when people's health or mobility changed. However, some records did not consistently explain how staff should manage risks associated with pressure damage, catheter care, diabetes, moving and handling, paraffin-based products and deteriorating health.

The provider detected and managed risks within people’s home environments. Environmental risk assessments considered people’s individual circumstances, equipment and potential hazards, and staff understood how to respond to falls, emergencies and concerns about equipment. Leaders worked with relevant professionals where additional equipment or support was required. During the assessment, the provider agreed to strengthen fire-safety records by making clear who was responsible for checking smoke-detection equipment and whether people required support or reminders to complete these checks.

The provider did not always ensure recruitment, training and staff-monitoring systems provided clear assurance that staff were suitably recruited, supported and competent. People and relatives were generally positive about care staff, and staff said they felt supported, had access to out-of-hours advice and had sufficient time to provide care. However, some recruitment records contained gaps in employment histories and references, while training and supervision trackers did not clearly demonstrate completion, compliance or follow-up of overdue activity. The provider had strengthened local oversight and introduced electronic monitoring of care calls. Surveys and other records reviewed during the assessment identified some concerns about punctuality, communication and continuity of care staff, although feedback about the care workers themselves was usually positive.

The provider assessed and managed the risk of infection. Staff had received infection-prevention training, understood required precautions and had access to personal protective equipment. People and relatives did not raise concerns about infection-control practice. The infection-control lead described additional precautions introduced in response to a person’s specific infection risk, including reinforcing appropriate hand hygiene and making additional protective equipment available to staff.

The provider did not always ensure medicines records were clear, accurate and consistently completed. Medicines policies, training, audits and competency processes were in place, and individual audit findings had resulted in staff reminders, refresher training and increased checks. However, records contained missing signatures, inconsistent administration codes and unclear information about responsibility for some medicines. Leaders investigated the concerns, clarified that insulin was administered by district nurses and strengthened senior oversight, but the recurring recording issues meant medicines systems were not yet consistently reliable.