CSM Care Services LTD

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 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.

We found the provider was in breach of the regulation relating to the governance and oversight of the service.

This service scored 62 (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 focused on person-centred care, staff development and continuous improvement. Leaders described a clear vision for the service and staff spoke positively about the organisation’s culture, describing managers as approachable and supportive. Leaders had recognised the need to strengthen local oversight and had invested in additional leadership and support arrangements. Throughout the assessment, leaders were open to feedback, reflected on the concerns raised and took action to improve the service.

Leaders were compassionate, inclusive and responsive to people and staff. Staff described managers as approachable and said advice and support were available when required, including outside normal office hours. The provider had strengthened local leadership arrangements, which had contributed to improvements in care documentation, staff support, monitoring and communication. Leaders demonstrated knowledge of the service, reflected openly on areas requiring improvement and responded constructively when concerns were raised during the assessment.

The provider promoted a culture in which staff could speak up and raise concerns. Staff described managers as approachable and said they felt confident seeking advice or reporting issues. Team meetings, supervision and regular communication provided opportunities for staff to discuss concerns, share learning and identify changes needed in people’s care. Records showed staff openly raised operational and practice issues and that leaders considered and responded to the matters brought to their attention.

The provider valued diversity within its workforce and aimed to ensure staff were treated fairly and supported according to their individual circumstances. Staff spoke positively about the support they received and did not raise concerns about unfair treatment or exclusion. The provider had supported staff relocating to the area, including providing temporary accommodation, and staff said they were able to take annual leave and maintain contact with their families. Policies and working arrangements promoted equality, diversity and inclusion.

The provider did not operate effective governance systems to assess, monitor and improve the quality and safety of the service. Although audits, care-plan reviews, staff monitoring, surveys and quality meetings were in place, these systems failed to provide leaders with reliable assurance that people were receiving safe and effective care.

The assessment identified significant shortfalls in care plans, risk assessments, medicines records, recruitment documentation and statutory reporting processes which had not been identified or effectively addressed through the provider's own governance arrangements. Information relating to people's health conditions, risks and support needs was not always complete, accurate or current, meaning staff did not consistently have access to sufficient guidance to support safe care. Governance systems had also failed to ensure all required recruitment information had been obtained, medicines records were accurate and complete, and notifiable incidents were recognised and reported appropriately.

The breadth of the concerns identified demonstrated that governance systems were not operating effectively to assess, monitor and mitigate risks to people or to drive improvement in the quality and safety of the service. Leaders responded positively and undertook substantial improvement work during the assessment. However, many of these actions were implemented after the concerns had been identified through the assessment process and the provider had not demonstrated that the improvements were fully embedded or consistently effective.

The provider worked collaboratively with partners and other services to support people. Staff and leaders communicated with healthcare professionals, commissioners, safeguarding teams and other agencies involved in people’s care. Records contained examples of joint working to respond to changes in health, access equipment and support individual needs. Feedback from an external social care professional described the provider as responsive, easy to engage with and willing to investigate concerns and share the outcomes.

The provider demonstrated a commitment to learning and improvement. Leaders reviewed incidents, complaints, safeguarding concerns and feedback and described learning relating to recognising deterioration, escalation, medicines, professional boundaries and statutory reporting. Learning was shared through staff meetings, supervision, training, competency assessments and changes to care documentation. Leaders were receptive to feedback during the assessment and introduced improvements to local oversight, monitoring, care records, medicines and recruitment processes.