Date of assessment: 26 February 2026 to 17 March 2026. This service is a domiciliary care service registered to provide personal care for people living in their own homes in the community. They provide support to people with a range of different needs including older people, people with dementia and people with physical disabilities. At the time of the assessment 30 people were using the service who were receiving the regulated activity of personal care. Not everyone who uses a domiciliary service receives personal care. CQC only inspects where people receive personal care. The service had a targeted inspection in December 2025 and was previously rated requires improvement overall, with a breach of regulation 17 relating to good governance. At this inspection some improvements were identified in relation to record keeping however concerns were also identified in relation to safeguarding and managing complaints. The service remains in breach of regulation 17, a breach of regulation 13 in relation to safeguarding was identified, the service has been rated requires improvement overall. CQC could not be assured that recruitment was always completed safely, as some gaps in recruitment records were found. Although steps were taken following the assessment to mitigate the risks associated with this, processes in place at the service had not been effective in preventing issues arising. Safeguarding concerns were not reported in line with current expectations and investigations and complaints handling were not completed in line with the providers processes. Risks associated with infection control and the care environment were well managed. Medicines were manged safely and records relating to medicines were regularly monitored. People and their relatives were involved in creating care plans, these were clearly documented and reviewed when required. Staff understood how to seek consent from people prior to providing care and care records evidenced the service understood how to work within the principles of the Mental Capacity Act (2005). Although the services record keeping practices had improved from the last inspection, there remained areas for improvement. Roles and responsibilities within the management team were not always clear, complaints were not well managed, and the provider had failed to refer a safeguarding incident to the Local Authority safeguarding team and CQC in line with expectations.
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Date of Assessment: 4 December 2025 to 16 December 2025. This service is a domiciliary care service registered to provide personal care for people living in their own homes in the community. They provide support to people with a range of different needs including older people, people with dementia and people with physical disabilities. At the time of the assessment 30 people were using the service who were receiving the regulated activity of personal care. Not everyone who uses a domiciliary service receives personal care. CQC only inspects where people receive personal care. We rated this service under our previous methodology in July 2023 where it was inspected and rated as requires improvement overall. At this assessment we found that the service had recently undergone several changes in management. A new team was in the process of implementing changes and improvements to the service. For this reason, the assessment focussed on 5 quality statements; Learning culture, Safeguarding, Safe environments, Delivering evidence-based care and treatment and Governance, Management and sustainability. The services rating has remained requires improvement at. The provider remained in breach of regulation in relation to good governance. Although improvements were being undertaken, these had not been in place long enough to evidence a sufficient improvement. Records did not evidence that learning was always undertaken following incidents. A new management team in place at the service had plans to improve this area and were in the process of reviewing records and policies. More time was needed for the service to improve in this area. Staff demonstrated an understanding of safeguarding and how to report concerns, however records did not always evidence that appropriate training had previously taken place or that this was up to date. Managers at the service had recognised shortfalls in training and were in the process of addressing this issue and improving policy and process. Managers and staff understood the need to be aware of and monitor the safety of the care environment including equipment maintenance. Systems and processes were being implemented to improve this area however records at the time of the inspection were not sufficient to assure inspectors that a robust environmental assessment and ongoing monitoring had always taken place. Systems and processes were in place to deliver care in line with best practice, and people and their relatives spoke positively about the care they received. Governance and auditing at the service was not sufficient to assure inspectors that managers would be alerted quickly if something went wrong. Managers at the service had plans for improvements to governance and some of these were in place, however records lacked detail and the effectiveness of these processes could not be demonstrated.
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Care 4 U Care Limited was rated Requires Improvement overall following a remote inspection in July 2023, with breaches found in governance (Regulation 17) due to absent systems for monitoring medicines, call times, and care planning. Staff and people spoke positively about the caring culture and the registered manager, but the provider's failure to understand duty of candour obligations and lack of formal oversight systems posed risks to sustained quality and safety.
Concerns (6)
criticalGovernance: “Systems had not been established to assess, monitor and improve the safety and quality of the service. This was a breach of regulation 17(1) of the Health and Social Care Act 2008.”
criticalIncident learning: “The registered manager was not up to date with their responsibilities under the duty of candour. In addition, they were not aware of the requirement to notify CQC of various incidents.”
moderateMedication management: “Staff had not received up to date medicines training or had an assessment of competency. There were no audits taking place of medicines to ensure they were being administered safely.”
moderateStaff training: “There was no effective system to identify when staff required up to date training or to show the level of compliance with training.”
moderateMissed or late visits: “The provider had no system to monitor calls. They were reliant on people or relative's telling them there had been missed or late calls.”
moderateRecord keeping: “There were no governance systems to ensure medicines, call times, risk management and care planning checks were taking place.”
Strengths
· People felt very safe and were happy with the care provided; relatives expressed confidence in staff and the registered manager.
· Staff were recruited safely with appropriate pre-employment checks and there were enough staff to support people.
· Risks were assessed and support plans were tailored to each individual, with information communicated to staff.
· A positive, person-centred culture was in place; people were included in decisions about their care.
· Staff received regular supervision, attended staff meetings, and felt supported by management.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people; Learning lessons when things go wrongGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
well-led: Duty of candour, regulatory requirements and governance oversightRequires improvement
well-led: Promoting a positive, person-centred and inclusive cultureGood
well-led: Engaging and involving people, public and staffGood
Care 4 U Care Limited, a domiciliary care agency supporting approximately 60 people, was rated Good across all five key questions at its October 2017 inspection. Minor shortfalls were noted in audit documentation, MAR record completion, capacity decision recording and annual appraisals, though no regulatory breaches were identified.
Concerns (4)
moderateRecord keeping: “some records had gaps where staff should have signed. We raise this with the registered manager who was already in the process of looking into this.”
minorConsent / capacity: “Where people lacked capacity, their representatives were involved in making decisions in the person's best interest. However, these decisions needed recording in people's care records.”
minorSupervision / appraisal: “Annual appraisals to discuss training needs and work performance were not routinely taking place. However, the office manager had devised a format to enable these to take place more regularly.”
minorGovernance: “systems to record audits which had been undertaken required further documentation.”
Strengths
· People consistently reported feeling safe and well-supported by kind, caring and respectful staff
· Robust safeguarding procedures in place with staff able to articulate actions to take if abuse suspected
· Safe recruitment system including DBS checks and structured induction with Care Certificate
· Comprehensive risk assessments in place covering environmental, mobility and medication risks
· Effective medicines management with MAR records and competency checks for staff administering medication
Care 4 U Care Limited was rated Good overall following an announced inspection on 13 and 18 August 2015, with staff praised for kind, person-centred care and robust safeguarding and recruitment practices. The Well-Led domain was rated Requires Improvement due to undocumented quality audits, incomplete medication administration records, and infrequent staff meetings undermining governance and communication.
Concerns (5)
moderateRecord keeping: “the audits that were undertaken were not always formally documented to evidence what had been identified, what required attention and who was responsible”
moderateMedication management: “medicines were not always recorded following the procedure. The staff had recorded in the daily records but had not always completed the medication administration record”
moderateGovernance: “There was no formal documentation of audits... the care coordinators told us they went out to visit people...to monitor the quality of care delivery...This was not documented.”
minorCommunication with families: “Staff meetings were not held regularly and staff told us communication and sharing of information could be improved.”
minorCare planning: “We looked at six care and support plans in detail and found the care files did not always reflect people's needs and preferences.”
Strengths
· Staff demonstrated a good understanding of safeguarding procedures and whistleblowing, with lessons learned following a local authority safeguarding investigation.
· Robust recruitment procedures in place including DBS checks, formal interviews, two written references, and a full induction programme.
· People received consistent care from the same staff members, supporting continuity especially for those living with dementia.
· Staff received formal supervision, annual appraisals, and a structured training programme including dementia awareness and MCA/DoLS.
· People and relatives spoke highly of staff, describing them as kind, patient, caring and respectful of dignity and privacy.
Quality-Statement breakdown (14)
safe: Safeguarding and protection from abuseGood
safe: Medication managementGood
safe: Risk assessment and care planningGood
safe: Staffing levels and recruitmentGood
effective: Staff training and competencyGood
effective: Mental Capacity Act compliance and consentGood
effective: Supervision and appraisalGood
caring: Person-centred care and dignityGood
well-led: Working in partnership with othersGood
caring: Involvement in care planning
Good
responsive: Care planning and responsiveness to needsGood
responsive: Complaints handlingGood
well-led: Quality assurance and governanceRequires improvement
well-led: Staff communication and meetingsRequires improvement