Carerose Cares 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 good. 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.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 46 (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 always have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There was a clear vision and ethos for being person centred and enabling, however there was very little documented evidence to support that the provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The culture of the service was not always open and transparent. For example, we found notifiable incidents that had not been reported to CQC, this is a statutory requirement and a breach of regulation.

The provider quality improvement strategy did not support the long-term stability or operational sustainability of the service resulting in unclear priorities or a reactive rather than proactive approach to improving. For example, there was not a proactive culture in identifying the concerns highlighted in this report, instead the provider was reactive to our feedback.

Leaders did not use their skills, knowledge, experience and credibility to lead effectively, and they did not always work openly with other professionals.

The leadership team comprised of 2 registered managers, 1 of whom supported our assessment and a field supervisor. We did not meet the second registered manager who also acts as the nominated individual. The registered manager told us they plan to employ a care co-ordinator to help with day-to-day oversight of the service.

A relative said, “I have no problems with the management team. They are very friendly.”

We found the registered manager to be friendly and compassionate, open to our feedback and willing to adapt their ways of working. The registered manager did not try to hide where their system’s fell short. Instead, the registered manager was open and honest with us on the day of assessment. For example, when we asked for investigation notes, the registered manager said, “I haven’t got any.” When we asked for other documentation, the registered manager was unable to access documents online, and explained their online files are not coordinated or organised in a way that means documents can be easily identified or found.

The registered manager is responsible for care plans and risk assessments. The registered manager is also responsible for auditing the care plans and risk assessments and did not always identify where these documents were not sufficient. For example, the managers monthly audit completed in April 2026 stated, care plans audited demonstrated good compliance with person centred planning principles and incorporated associated risk assessments. The audit did not identify the concerns identified during our assessment which included, no manual handling risk assessments, no fire risk assessment and no financial risk assessment for 1 person who staff sometimes purchase items for.

This meant the provider failed to have effective and robust systems in place needed for effective oversight.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and people told us that they felt able to speak and raise concerns to the registered manager. Staff and people also knew where to report concerns if they were not satisfiedwith how the service dealt with them, such as the local authority.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act. The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

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.

This assessment highlighted the registered manager did not have oversight of the fundamental areas of running a safe service such as accidents, incidents safeguarding’s or themes and trends.
The provider failed to implement a robust quality assurance process which effectively analyses incidents and identifies what went wrong.

This meant the provider did not always have oversight of accidents or incidents which took place in the service and did not always take action to mitigate potential risk and harm to people. Lessons were not always learnt to reduce reoccurrence.

The service failed to identify where serious incidents met the threshold for safeguarding’s and therefore safeguarding procedures were not followed. This means there was a missed opportunity to learn and strengthen risk mitigation.

We discussed the quality assurance process in place with the manager who understood improvements were needed to ensure the safety and quality of the service provided could be fully monitored. We discussed the need to set up a robust quality assurance system, which must be in place. The registered manager acknowledged their governance systems had failed and sent CQC an action plan setting out how and when they would improve.

At the time of the assessment the registered manager told us they have made an organisational decision to focus on strengthening their governance and therefore decided not to consider taking any further care packages at this moment in time.

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.

The registered manager told us they work in partnership with other professionals, however at the time of our assessment we did not see evidence to support this.

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.

The provider failed to have systems in place to encourage creative ways of delivering equality of experience, outcome and quality of life for people.

There were significant and widespread concerns identified during this assessment. The registered manager could not evidence that action had been taken to learn and improve the quality of the service through internal audits or lessons learnt reviews.

The provider failed to implement a consistent approach to measure outcomes, utilise best practice guidance and monitor the impact and quality of care for people.

The lack of systems to monitor effective practice in areas such as safeguarding and risk mitigation put people at risk of harm. For example, the provider had identified a safeguarding incident where a person had been injured during manual handling. They then failed to identify people did not have robust care plans and risk assessments to support safe moving and handling. This meant the provider did not learn from the incident and people were at risk of avoidable discomfort or harm.