Caroline Cares for You Ltd

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• 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

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 oversight of the service. Their auditing systems and oversight had failed to identify shortfalls we found in consent, medicines optimisation and safeguarding.

This service scored 61 (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 had a shared vision, strategy and culture, but the shortfalls in their governance meant the direction of the organisation did not focus on quality assurance.

There was an open culture in the service. Although we found the provider had not reported events and incidents to the relevant agencies, this was due to a lack of understanding, and not the adoption of a closed culture.

Work was required to clearly define the strategic direction in relation to governance and quality assurance and how this would be strengthened.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

We found that leaders and managers were compassionate, and often still involved in care delivery which kept many of their skills to a good standard and fed their passion for the work they did.

There were some shortfalls in knowledge including regulation and legislation. This was reflected in the failure to identify issues within the service, as audits were completed but not thoroughly or to a good standard. Additionally, some language used within care plans written by managers or leaders, was disrespectful, for example, some inappropriate terms used in reference to incontinence care.

The provider took immediate steps to rectify these concerns and managers had completed additional, in depth, training courses in these areas before our assessment had finished.

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

The provider had a whistleblowing policy, which laid out a clear process and signposted people to external organisations. There was room for improvement to ensure it detailed all relevant organisations and included their contact information.

Staff told us they felt comfortable to speak up, and that managers and leaders were approachable. Staff told us they were confident they would be listened to and respected if they were to speak up. Staff also had good knowledge of where they should go to raise concerns externally, if the response internally was not satisfactory.

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.

Staff who required reasonable adjustments, or had health conditions that could impact their work, received adequate support and adjustments to their duties, which did not impact the experience of people using the service.

Some staff told us that when they had faced difficult personal circumstances, they were supported to continue working or encouraged to take time off to recover by the provider.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found that the oversight of the service was not adequate. Some audit tools used were not fit for purpose, and others were not being utilised effectively, therefore the provider had not identified issues within their service.

Managers and leaders were not fulfilling their statutory duty to report certain events and incidents to the CQC, additionally, they were not clear on their responsibility around safeguarding and raising alerts to the Local Authority.

The service was owned by a different organisation, and their oversight was also not adequate. They had taken over in June 2025 but not identified the concerns we found during our assessment or taken action to rectify these.

The provider had a positive presence within the local community, and operated a community hub, which doubled up as an office.

People looking to source care for their loved ones, were able to come into the community hub and get advice and guidance, with no obligation to choose the provider to provide that care.

The provider had a charity strategy and was involved many events to raise money for local and national charities.

The provider was involved in initiatives such as planting trees in the national college, and attending local colleges to speak to young people about pursuing a career in health and social care.

The provider focused on continuous learning, and they were quick to respond and embed changes to their service, following our feedback. However, the tools they used to ensure oversight of the service were not utilised adequately, or were not fit for purpose, which did not provide the opportunity to learn and improve the service.

There was some evidence that the provider was responsive to issues when they arose, the provider had not demonstrated a proactive and innovative approach to improving the service. Further work was needed to strengthen the governance processes and ensure continuous learning and improvement led to better outcomes for people.