Care By Us 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.

At our last assessment we rated this key question Outstanding. At this assessment the rating has changed to 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.

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.

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

We received mixed feedback from staff regarding their experiences of management at the service, and this varied between each area of the service. Whilst some staff felt supported on a day-to day basis, other staff felt unable to approach managers. One member of staff told us, “I can always approach my manager. They are supportive.” Another member of staff told us, “The previous manager was a team player. Now they (manager) just sit in the office, and they don’t know people.”

It was clear from the feedback we received that changes in managers had created instability amongst staff and some staff were dissatisfied following poor experiences. We shared these concerns with the provider who assured us they would be addressed.

The service had one registered manager in post at the time of our assessment; however, they were responsible for the ‘live in’ area of service and were not involved in the overall management of the registered location. They confirmed they had no operational knowledge of other areas of service provision.

One registered manager had left employment at the service shortly before our assessment commenced on 23 October 2024. A statutory notification to inform the CQC of their absence and the management arrangements in place, was not submitted until 04 December 2025.

At the time of our assessment, the provider had made an application to make changes to their registration to separate the service into 3 registered locations. During the time our assessment was conducted, one change to the providers registration was completed.

The provider was in the process of recruiting a new registered manager. Each area of the service had a manager, and the overall registered location was being led by 2 senior staff from the provider organisation.

Shortly after our assessment concluded, the manager of the supported living area of the service was appointed to a registered manager position. During the registration process, it was confirmed that the existing registered manager would be responsible for all areas of the service providing domiciliary care and the new registered manager would continue to be responsible for the supported living area of the service.

We received mixed feedback from staff. Whilst some staff felt able to speak up, other staff told us they were not always confident to raise questions or concerns. One member of staff told us, “I do not feel like staff have a chance to air out ideas or grievances. [Name of area of the service] have some of the best carers, but they are not happy, and it would be a shame to lose them.”

Staff meetings and handovers were held differently across the areas of the service. Where meetings were held, some staff told us that they were not provided with opportunities to speak up and felt that they “were spoken at, rather than encouraged to talk.”

It was clear from some of our engagement with staff for the assessment process that they were reluctant to raise any concerns or share feedback that could be viewed as negative, which could lead to them being identified by managers.

All staff confirmed they were aware of the whistleblower process in place.

The provider had a whistleblower policy in place. Details of organisations who staff could report whistleblower concerns to were included.

The provider was unable to provide us with any records of whistleblower concerns received but was able to share an example of action taken in response following contact from the local authority.

Whilst these processes were in place, it was clear from staff feedback that improvements were needed to improve the culture so that staff felt they could speak up and be heard.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Most staff told us they knew their roles and what was expected of them. However, we received mixed feedback regarding the management processes in place with many staff not able to confirm any part where they felt able to contribute to driving improvements within the area of the service they worked. One member of staff told us, “We have regular meetings. We are given feedback and talk through a whole range of information, ideas and ways of working.” Another member of staff told us, “There have been a couple of meetings, but [Name of manger] takes over the meeting and talks over us. It feels like [they are] dictating to us so no one wants to speak up or contribute.”

The provider had a quality assurance system, which was supported by a policy and a process. This was not being operated effectively at the service.

We reviewed a range of staff survey and engagement results, internal audits and checks, system records relating to accidents, incidents, complaints and untoward events and feedback obtained by the provider regarding the experiences of people receiving a service.

We found that, whilst a series of internal audits and checks were in place, these were not always completed accurately. For instance, we found examples where ‘record book audits’ stated that people’s care visits were greater than 90% punctual. When compared with call data, this was inaccurate, and people’s care visits were not punctual as described. In contrast, other audits stated that actions were needed, yet no concerns had been identified in the time period the audit reviewed.

We also found instances where improvements were identified as needed, but these were then not recorded in the resulting actions. For example, for one person we saw that 3 improvements of service were identified however, only one was then recorded as an action. This meant we could not be assured that all actions identified as being needed were taken to improve the experiences of people.

We found examples where ‘care plan management audits’ stated that care plans in place were ‘compliant’ with the standards set by the provider and no action was needed. However, the same audit then described additional detail was needed within the care plan document. In one example, a care plan was deemed ‘compliant’ yet actions recorded as needed detailed improvements were needed in relation to tasks being completed in care visits, more information was needed in the person’s life story and an MCA (Mental Capacity Assessment) was to be completed.

As described in the safe domain of this report, we found that risk assessments were not always reflective of people’s needs or included all relevant information and that records in relation to people’s medicines contained anomalies. These discrepancies had not been identified by the providers system to identify and manage risk, or subsequent audits and checks.

The provider shared with us the most recent ‘quality audit’ completed for each area of the service. The results of these varied from 66.4% to 93.2% compliance with the expected standards set by the provider. Due to the inconsistencies we found within some of the internal audits and checks, we could not be assured of the robustness of overall audits or that the resulting ‘compliance’ scores were based on wholly accurate information.

Following our assessment, the provider shared the overarching improvement plans for each area of the service. We found that some actions signed off as having been ‘completed’ prior to, and at the time of our assessment, remained areas where improvement was needed as identified in this report.

Notifications had not been submitted to CQC as required for all reportable events. Where they had been submitted, they lacked information and detail. Some submissions were also delayed. The provider confirmed they would provide additional support to staff to ensure that notifications were completed fully and in a timely way.

By failing to operate the quality assurance process effectively the managers, and subsequently the provider, did not have effective oversight of the service. The provider had not ensured that accurate information regarding risk, performance and outcomes was being used to take action.

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.