Care Staff 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

At our last assessment the provider was in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

This service scored 36 (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 based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a lack of leadership, management understanding and planning to improve the standard of the service. The service lacked vision and did not have systems in place to monitor the culture of the service or how people were supported. The standard of care people received was dependant on the skills of the individual staff members supporting them with no overall strategy as to how the service would offer consistently good care.

The manager told us they were concerned about the level of skill and capability of some staff members and felt a programme of upskilling was required. Despite this, spot checks had not been completed for some staff for over 3 months. This meant their standard of work had not been observed to ensure a positive culture was being promoted and feedback had not been gathered from the people they were supporting.

The manager shared the values they wished to see within the service going forward. However, whilst discussions with staff had begun regarding having a more open dialogue, there was no systematic plan in place to develop and embed, monitor and sustain these principles.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

There was a lack of understanding regarding planning and risk management to ensure a smooth handover when the overall management of Care Staff Services changed. This had resulted in one manager and one care co-ordinator being responsible for the safe, effective delivery of care to over 100 people. Office functions such as HR, quality assurance, management support and administration had all left the service. The provider did not demonstrate an understanding of the key roles required to run the service or how these were going to be filled. The manager told us it was the provider’s intention to employ 3 consultants to support the development of the service. However, they had not established what roles the consultants were going to take or what tasks were required to ensure a smooth service delivery.

Whilst the manager was able to highlight areas of concern they needed to review, due to the size of the service and competing demands they were unable to ensure these were addressed or implement systems to monitor standards. This showed a lack of leadership, planning, skill and understanding of business continuity planning by the provider. This put people at risk and failed to ensure they received safe, effective and responsive care.

People did not always feel they could speak up and that their voice would be heard.

Prior to our assessment of the service, we reviewed information received by CQC since our last assessment. This showed staff had consistently contacted CQC to express a variety of concerns regarding the service. These included employment issues, concerns for people’s safety, poor management communication and staff not feeling listened to.

During our assessment staff told us they felt things were beginning to improve since the new manager had started as they were more approachable and had encouraged them to be more open. The manager re-iterated this and told us they wanted staff to feel supported although recognised it would take time to build trust. Despite these comments, we found that with the exception of contacting the office directly, there were few other systems in place to support staff in speaking up and no records were made of conversations had with staff in order to monitor themes.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We received mixed responses from staff regarding equality and diversity within the workforce. Some staff had reported they felt discriminated against due to coming to work for the service from overseas. They felt due to this they were not always treated with respect, and their work was not always valued. Other staff told us they felt improvements were being made under the new manager and felt communication had become more respectful and understanding.

The manager told us they were in the process of implementing systems to support staff and ensure they felt their culture, ethnicity and diverse needs were respected. They told us, “We need a good mix of staff, and we will now be advertising posts openly to encourage applications from all different backgrounds.” They gave examples of how the service had started to work flexibly so staff were able practice their faith and also accommodate staff’s personal commitments.

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.

Following our assessment in June 2025, conditions were placed on the provider’s registration directing them to submit audit and governance information to CQC every 2 weeks. At the time of our inspection, no information had been submitted for a period of 8 weeks. The manager told us they had not send the information as they considered audits sent by the previous management team had not been accurate or transparent regarding the situation at the service. They therefore felt this exercise was unhelpful in addressing the shortfalls they had identified. However, no contact had been made with CQC to express this as a concern, detail why their legal obligation to comply with conditions on their registration were not being met, or to demonstrate how the service was mitigating the on-going risks they had identified.

The provider did not have a systematic approach to quality assurance and had not completed audits since the previous management team had left. They told us a mock CQC assessment had been commissioned from an external consultant. This had rated the service inadequate and found multiple breaches of regulation. Despite these on-going concerns, the service action plan had not been updated and no responsive risk management protocols implemented to address shortfalls where urgent improvements were needed.

Accurate, contemporaneous records of the care people received were not maintained. Daily records lacked detail and did not reflect the support people received was in line with their planned care. In addition, we found the language used in daily care records was not always clear, making it difficult to understand how people were, what care they had received or if any follow-up was required. We found the terminology used by staff to describe people’s care was on occasion undignified.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Whilst there had been some improvement in how the service worked alongside partner agencies, this was not consistent. Feedback received demonstrated partner agencies continued to have concerns regarding the transparency of information the provider shared and expressed frustration at not receiving information requested in a timely manner. This presented difficulties for other professionals involved to monitor the quality and sustainability of the service.

In other areas we found the service was more transparent in their approach to sharing concerns. At our last assessment we identified concerns regarding the lack of reporting to CQC and external agencies when significant events occurred. We found improvements had been made in this area and the service was now submitting notifications in line with their statutory responsibilities.

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.

Following our last assessment the provider had developed an action plan highlighting where improvements were required. The plan highlighted where the provider felt the improvements had been achieved. The manager told us that as a result of their reviewing documents and the mock CQC audit results, they did not feel the plan was an accurate representation of the progress the service had made. Despite this, no further action had been taken to highlight how improvements would be made. This meant there was no structured or credible improvement plan in place. The provider had not identified who would take responsibility for actions, how improvements would be monitored, what success would look like, or the timescales for completion. Without these essential governance elements, there was no assurance that improvements would be delivered, sustained or evaluated.

Our assessment identified continued breaches of regulation in respect of people receiving person-centred care, how consent to care was determined, people’s safety and well-being, staff support and recruitment and good governance.