Admiral Care Limited

Updated 19 November 2025

We visited the site on 21, 26 and 28 November 2025. We identified significant shortfalls in how the service assessed and managed risks to people. Systems were unreliable and did not support learning from incidents. Safeguarding arrangements were inconsistent and the knowledge of staff and leaders was varied. Issues with medicines, missed or late visits and a lack of health monitoring increased the risk to people of avoidable harm.

We found the service did not consistently provide care which focussed on good outcomes for people. Care plans and assessments of people’s needs were often incomplete, outdated and not shared with people. This limited guidance for staff on how to deliver high quality, effective care. Legal duties, including those outlined in the Mental Capacity Act, were not always understood or followed.

We found some people and relatives spoke positively about staff kindness. However, this was not consistent across the service. Care was not always respectful or individualised, records sometimes contained inappropriate language. Care plans did not include details about people’s preferences, backgrounds and goals.

We found the service did not always adapt care to meet people’s needs. Care call times and staff attending depended on availability rather than people’s preference or to maintain continuity of care. People were not regularly involved in reviewing their care. Feedback and complaints were inconsistently managed and not used to drive improvement.

Leadership and oversight was insufficient and did not provide assurance of safe, high quality care. Governance systems were weak or absent and failed to identify significant risks. Records were incomplete and audits were ineffective. Staff could raise concerns, but not all felt supported by leaders. The previous inspection identified 3 breaches of regulations. These had not been resolved on this inspection, and further breaches were identified.

During this inspection we identified 8 breaches of regulation. This included person-centred care, consent, safe care and treatment, safeguarding, complaints, good governance, staffing and notifying CQC of incidents. We have asked the provider for an action plan in response to the concerns found at this assessment

Updated 19 November 2025

People and their relatives were largely positive about their care. Most spoke of staff as kind, and said staff listen to them. Feedback included, “Yes they are very kind, they offer to do things for me. They speak kind words”, “Yes, they show kindness when I am there.” And “The staff are very kind and caring.”

People told us they discuss their care with the care staff, but most had not seen a care plan and some had not been involved in their care planning.

Most people and relatives told us they felt safe, 1 person said, “Yes, I do feel safe with the carers.” While we received some concerns about safety and openness. A relative said, “No I don’t feel that [person] is safe.” They fed back that incidents were not communicated transparently and complaints were not resolved.

Most people told us there were enough staff, though some fed back that they did not have consistency in care staff. People told us they are not sent a rota ahead of visits. A relative said, “They change [staff] often but I know some of them.” Another said “They are not consistent.”