Carerose Cares Limited

On this page

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

The service was in breach of legal regulation in relation to people’s safe care and safeguarding.

This service scored 53 (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 proactive and positive culture of safety based on openness and honesty. They did not identify concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The registered manager was open and transparent with us during the assessment and told us systems were not in place to record, investigate or learn from incidents.

The registered manager had difficulties accessing online records at the time of the assessment further evidencing their systems were not effective.

Some incidents that had been recorded related to people, for example, when one person sustained an injury. However, this was not investigated, and the incident had not been reported to the local authority or CQC.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

They made sure there was continuity of care, including when people moved between different services.

Staff told us they read through care plans and that they knew people well.

The registered manager told us how they had shared information with other health professionals when needed to ensure a smooth transition between services.

The provider did not consistently identify, document, escalate and report safeguarding concerns appropriately.

The registered manager told us about a safeguarding incident that took place during late 2025. The registered manager told us the incident had been investigated. However, was unable to share any recorded documentation related to the safeguarding or any learning outcomes with us.

The provider did not have effective systems in place to manage complaints, accidents or incidents. From the incidents that were recorded we identified 3 reportable incidents that the provider had not identified as safeguarding’s, for example when one person attempted to overdose. The person received medical help, however the incident was not reported to the local authority safeguarding team or to CQC through a statutory notification.

The registered manager acknowledged their failings in identifying reportable incidents and safeguarding’s and told us they would make improvements.
 

The provider did not always work well with people to understand and manage risks.

People told us they were involved in their care planning and risk assessments. Some risk assessments were very detailed, whilst key areas such as manual handling and fire safety lacked information to mitigate risk to people or were not in place at all. For example, we identified one person who used equipment for transfers and a wheelchair had no manual handing risk assessments in place.

Staff practice and people’s capacity to inform staff what support was needed helped mitigate risk to people because the staff team and people being supported had long standing professional relationships.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider was providing care and support to people in their own homes therefore some aspects of environmental safety were outside of the provider’s control. However, environmental risk assessments did not always contain sufficient detail regarding staff responsibilities for environmental safety before leaving people’s homes, including checking relevant appliances and securing key safes.
This created a potential risk that required strengthening within care documentation.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager had processes in place to ensure all staff received an induction and staff told us they had enough training. Appropriate checks were in place before staff started work including providing full work histories, references and a Disclosure and Barring Service (DBS) check. DBS provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The registered manager spoke highly of the staff team.

Staff told us they worked well together, 1 staff member said, “We have built a strong team through regular meetings, training, and supporting each other’s understanding of matters, we have good communication.” Another said, “Staff work together using shared goals, clear communication, and mutual trust to get a job done.”

A relative said, “The care staff are really good and follow my instructions.” Another said, “My family member feels safe with the staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had infection prevention and control training,and used personal protective equipment provided by the provider.

People’s care plans had a planned outcome for the person to remain free from avoidable infections. There was detail for staff to follow to achieve this outcome which included, hand hygiene, the use of PPE, safe disposal of PPE and follow the World Health Organisation's "Five Moments for Hand Hygiene" approach.

A relative told us staff use PPE appropriately.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The registered manager told us they were supporting 1 person with their medication and staff had received medication training.

It was unclear in care plans if people were or were not being supported with medication. For example, the care plan for 1 person who self-medicates says, staff should prompt the person to take their medication and offer a glass of water. This could lead to confusion for staff about what they should be supporting people with, meaning people could be supported incorrectly with their medication.