SQ Carers 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 good. At this assessment the rating has changed to requires improvement. This meant the service was not consistently managed and well-led. Leaders and the culture they created did not always promote high-quality, person-centred care.

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

This service scored 39 (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.

The provider had not created a positive and open culture which consistently placed people at the centre of their care. People told us the provider did not always meet their expectations, particularly with regards to care call times and the lateness of these. Some people and relatives lacked confidence in the leadership of the service. The registered manager told us they were proud of the service. They said, “Clients have belief in me.” Whilst people told us they would contact the registered manager to raise issues, not everyone was confident improvements would be made and sustained.

The registered manager had not identified all the risks we feedback to them during our visit. The registered manager was unable to demonstrate a clear, shared direction for managing risks, overseeing tasks when delegated to others and driving improvements. This demonstrated limited opportunities to continuously improve.

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. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The registered manager did not lead by example. In the report, we have referred to examples where learning opportunities were not taken or practices improved. Staff told us they had repeatedly raised issues about the log in/log out process for care calls not being reliable. We asked the registered manager about this who could not give us a credible answer. We saw no evidence to support this being raised as an issue with their IT provider. When we asked for records required as part of this inspection, we had to make a formal request post our site visit. Some of the records we wanted to see, were either not supplied or eligible. In some cases, when we saw records, some were not consistent with each other meaning we could not be assured, people received the right level of support. The registered manager was responsible for this service and another registered location. They told us they were recruiting a deputy manager who would be able to support them with the management of the service.

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

People’s feedback was of a provider who did not always listen or act on feedback. On the spot observations of staff practice in people’s home, did not record people’s feedback, despite the form requiring this information. People gave us examples where they had shared feedback about care call timings. However, for some people, this had not improved.The provider had processes to support staff to speak up. This included supervision meetings, staff meetings and they had a whistleblowing policy for staff to refer. The registered manager said they were the initial point of contact for staff; however, staff would be referred to CQC if they wanted to raise any information of concern external of the provider.

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.

The registered manager described recent challenges due to issues around the provider’s overseas sponsorship licence for employees. Many of the staff team responsible for delivering care were either agency or on zero-hour contracts. The registered manager was looking to recruit new staff.

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.

The registered manager was dependent on their electronic system to hold, store and report on all aspects of their service. This system produced staff call rotas, assigning staff to people’s preferred times, logging staff in and out and creating and updating people’s care plans. The registered manager told us they did not utilise the reporting function within the system, so relied upon their own audits. When audits were completed, they lacked any detail, clarity and information to show what they had checked and found. Some monthly audits had not been reviewed since May 2026. We asked for examples of audits so we could see their effectiveness to drive improvement. Medicine audits had not identified discrepancies with medicines disguised in foods, failed to identify people’s care plan and daily record information supported the right level of care. Where gaps in care plans existed, they were not identified through provider checks. The main concern we found through a lack of effective audits, was the oversight of care calls. We had information from commissioners which showed a high number of care calls were completed outside of people’s preferred times.

There was no effective audit completed to show this, and what had been done to improve the service. Where checks were delegated to other staff, the registered manager did not have oversight. We asked for examples of people’s records numerous times during the visit. We were told they were on a laptop which could not be accessed as it maybe faulty, or, staff referred us to the registered manager, who referred us back to the staff member. There was complete lack of responsibility and understanding of key roles and responsibilities. The registered manager told us they utilised the services of an external business to clear ‘system alerts’. Although the registered manager told us this external business would not close clinical alerts, there was no system in place to ensure this was complied with. The registered manager had no control or effective process to operate robust quality assurance.

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

During this inspection, we experienced difficulties seeing and accessing the evidence and information we needed to make judgements against the 5 key questions. Post our site visit, we made a formal request to the provider for the information we needed as deadlines we agreed during our site visit were not adhered to. Commissioners we spoke with prior and post our site visit, found similar concerns in accessing and reviewing records. People and relatives said it was difficult to contact the registered manager or office staff. The registered manager told us they were addressing the lack of office contact by using the services of an external business. However, when we tried to contact the office, all we could do was leave telephone messages and we did not receive any call backs. Where health professionals’ input was sought, we could not be confident from speaking with the registered manager and staff, they followed this. For example, around the administration of covert medicines or supporting people with modified diets. Throughout this inspection, it was difficult getting the information we needed. Following our site visit, we made a formal request to the registered manager to get the information we needed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

During our visit, we found there were no effective systems to learn and improve across the providers services. Conversations with the registered manager and staff, showed a lack of understanding to improve.

The registered manager agreed they needed to improve their checks, as well as, understanding some of their decisions, such as passing alerts to an external company, without seeking people’s consent and agreement, was not well thought through. The registered manager told us they were changing their policies and procedures to another company. We found audits did not focus on specific issues and did not record what was checked, so they did not identify the issues we found or identify any learning. There was a lack of understanding of what an effective and robust audit was, which clearly impacted on how they learnt lessons.