CSS Care 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. For this key question we assessed the quality statements relating to; shared direction and culture, capable, compassionate and inclusive leaders, governance, management and sustainability, freedom to speak up and workforce equality, diversity and inclusion. We identified 2 breaches of the legal regulations. Leaders lacked a shared vision and strategies conflicted. Staff were not engaged when issues were identified, so they lacked understanding of ongoing challenges within the service. The roles of the director, the existing nominated individual and the manager were not clearly defined; and staff expressed confusion around who to seek support from. The provider failed to ensure recruitment of leaders was safe. Governance systems were poor and were not used to effectively record, monitor and improve standards. Staff and leaders were not following the providers own policies, meaning people were not always receiving consistent care in line with best practice guidance. Staff felt they were treated fairly and had the freedom to speak up.

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.

During conversations with leaders, it was apparent that they had limited knowledge and insight of their own strategies and vision for the future. The director and the manager spoke about the running of the service and plans for improvement, but responses conflicted.

Leaders did not demonstrate a positive listening culture that promoted trust or focused on learning and improvement. Throughout inspection people informed us of concerns they had raised previously, but we saw limited evidence information had been appropriately addressed or shared with staff.

Leaders did not have the experience, capacity, capability or integrity to ensure the organisation vision could be delivered and risks were well managed. When speaking to staff and leaders, it was not clear who was responsible for oversight, or the day to day running of the service. We were told the existing nominated individual had not received appropriate support or development within their role, and they were not fully aware of the requirements of the post. Though staff said they generally felt well-supported, some could not tell us who the current manager was. A staff member said, “I have never met the manager, I can’t remember her name.”

Recruitment systems for leaders were not safe or effective. The manager at the time of the assessment did not have a recruitment file and there was no evidence of an interview taking place. In addition, appropriate reference checks had not been sought from their previous employer as per best practice guidance. The existing nominated individual did not have a recruitment file in place and there were no records of the director’s DBS check despite them visiting people’s homes. Disclosure and Barring Service (DBS) checks provide information including details of convictions and cautions held on the Police National Computer.

Staff told us leaders encouraged them to raise concerns and were confident their voices were heard. Staff confirmed they attended team meetings periodically.

Leaders actively promoted staff empowerment. Whilst information was not available around the agenda, meeting minutes or attendees, staff meetings had taken place and another was scheduled shortly. Evidence of staff satisfaction surveys was also provided.

Leaders made reasonable adjustments to support staff if required. A staff member said, “I am treated fairly, I am supported with my medical needs.” Leaders took active steps to ensure staff represented the population of people using the service. For example: the service supported people from a range of cultures and the staff team were reflective of this.

Leaders took action to review and improve the culture of the organisation in the context of equality, diversity and inclusion. We saw evidence of an equality and diversity policy, and staff were able to raise concerns via the on-call system or in team meetings.

Staff and leaders identified a lack of clear and effective systems for governance or management within the service. Leaders acknowledged our concerns around oversight of several processes throughout assessment. For example: responding to incidents, creating care plans and recruitment. The existing nominated individual spoke to us about the statutory notification process. However, they could not confidently tell us appropriate audits or checks had been carried out, to ensure reportable incidents had been investigated and shared. Staff told us they did not know about or have time to read the provider’s policies. Therefore, we could not be assured they fully understood their roles and responsibilities.

When requesting information to aid the assessment process, it was clear arrangements were not robust to ensure the availability and integrity of data. There was no effective system to archive files relating to staff or people, leaders did not have up to date information relating to people’s care needs and there were gaps in records such as the staff training matrix. Information was not used effectively to monitor and improve the quality of care. Records were not consistently audited, which resulted in shortfalls such as care plans not being updated and medicines records being inaccurate. Policies were in place but were either not being followed; or staff and leaders were working against the guidance available within them.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.