Admiral Care Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safeguarding, staffing and safe care and treatment.

This service scored 31 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The culture within the service was not focused on improving safety based on openness and honesty. Since our last assessment there had been little improvement in the guidance for staff in relation to known risks to people. Further information for staff was needed about how the risks would be managed.

There was no system in place for analysing incidents and accidents. When we discussed this with the management team, they told us they would create a system to meet this need. This new process was shared with us after our feedback, however this incident analysis was limited to falls only, demonstrating a lack of understanding of management about what accident and incident analysis was. This meant there were missed opportunities to drive improvements within the service from lessons learnt in relation to when incidents occurred.

Incidents were not robustly investigated to ensure actions and learning was identified to reduce the likelihood of re-occurrence, and protect people from avoidable harm. For example, when safeguarding alerts were raised, there was an investigation, however this was not consistent and did not include detailed analysis of how such events occurred, or robust actions implemented to reduce the risk of reoccurrence. There was also no evidence any learning from incidents was shared with the wider staff team.

There was no system to share learning and support development for staff following incidents or concerns. Staff supervisions were not carried out regularly and appraisals were not completed at all. This meant there was no effective system in place to aid improvements in the service and safety of people with complex support needs.

Where complaints had been received, the action taken was not always robust and did not include analysis of the incident to reduce the risk of reoccurrence. For example, a complaint was made about missed visits, which resulted in no action being taken to review or change systems to reduce future risk.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

For example, one person’s health condition was recorded in the care plan, however this lacked information on how the condition impacted the person, which other professionals were involved in their care or when future appointments or medical reviews were due. Not all people who received care, had a copy of their care plan in their home to allow effective working with other professionals.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Most people we spoke to told us they felt safe receiving care from the service. Not all staff we spoke to were able to remember if they had received safeguarding training or when and staff had mixed levels of understanding of what actions they should take in the event of a safeguarding concern, though all staff said they would report a concern to the manager, not all staff were able to provide examples or immediate actions they would take.

The registered manager and compliance manager, told us they completed investigations when safeguarding events occurred, however there were no records maintained of investigations or demonstrating actions taken or identifying learning, and changes made to reduce the risk of reoccurrence. Some people and relatives told us they felt safe, however some stated they did not. One person’s relative said, “No I don’t feel that [person] is safe. [Person] has a big bruise…which was not observed or reported.“

Systems were not effective at identifying and acting on missed visits or medication. This was reliant on staff or the person reporting these potential safeguarding incidents which meant they may be missed and not investigated or reported. There was no system in place to identify when visits would be time-sensitive, such as when medication was required at a specific time, and no system to report late visits. People who used the service were not always given a time to expect the carer to arrive, and so late calls were not always identified or reported. One staff member told us regarding systems for informing people if care staff are running late, “[Office staff] sometimes inform the client but not always, it’s usually the clients who ask us why we’re late when we get there.”

Systems did not ensure people were supported to understand their rights, or ensure staff had information to ensure their rights were properly promoted to make decisions. Records regarding people’s mental capacity were not clear in the person’s care plan, or directly contradicted the requirements of the Mental Capacity Act (MCA). For example, one person’s care plan said, “[Person] has fluctuating capacity, carer’s to make decisions in their best interests,” though no records were in place to demonstrate the person lacked capacity related to any decisions, or of any best interests meetings and outcomes

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s risks were not consistently identified, assessed and managed to mitigate risk of harm to people. Of the 11 records we reviewed, none had robust assessments and management plans for risks including skin integrity, falls, choking or self-neglect. Restrictions, including using bed rails, did not have appropriate risk assessments in place and did not demonstrate consent was obtained, or alternatives considered.

People identified as at increased risk of falls did not have an effective management plan in place for staff to follow. A falls screening tool had been completed, however this tool stated if increased risk identified, falls management plan to be completed, however no person at risk of falls had this management plan in place at the time of inspection.

Care plans in place for instructing staff on managing risks, such as using equipment or using thickener for fluids, were inconsistent or lacking important information on how to safely care for the person. Monitoring or people’s health risks, such as constipation, was not in place. There were no plans in place to support staff to understand how to manage urinary catheters or stoma sites safely or monitor for concerns. People’s health conditions were not clearly described to support staff in identifying deterioration and escalation plans were not in place should they become unwell.

We discussed this with the registered manager who said they would review systems and processes and make necessary changes.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

For example, some people required equipment to mobilise and transfer safely. There was no system in place for ensuring equipment was monitored for safety for the person and staff using the equipment. Equipment was not regularly checked for wear and tear and service due dates were not recorded which would not support staff to ensure all equipment was safe to be used.

People’s risks related to fire were not always well considered, where a person had a known risks associated with hoarding were not reflected on personal emergency evacuation plans.

Where people had equipment, there was no evidence of checks of equipment being performed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There was no system to ensure staff were deployed on care calls in line with the needs and preferences of people. There was oversight of late or missed care calls but this was not robust, meaning people were at risk, particularly those who were unable to contact the service themselves.

A system was in place to allow weekly alerts to the compliance manager of which staff were due to complete training, however, there was no oversight of this, no records to demonstrate weekly checks were being completed of staff training. Staff did not receive training for specific conditions, for example diabetes, epilepsy or stoma care, even though they supported people with these needs. One staff member told us they did not do refresher training and no staff we spoke to were able to tell us about any training they had received for specific medical conditions.

We asked the registered manager and compliance manager how often staff received a supervision meeting, they said once a year.

Staff did not receive regular supervision and appraisal meetings. The provider’s supervision policy was not being followed. The policy stated staff would receive four supervisions each year which would be documented on the annual planner template. We asked for this document which was not submitted. We requested supervision records for staff and from the records we reviewed, only one supervision record for one staff member was seen.

The provider stated the undertook annual ‘spot checks’ of staff to review their competency. The provider was not undertaking these checks in line with their own policy. The provider completed a summary, which included 36 staff members, 10 of these staff had not received a spot check during 2025 and 2 staff had been identified as requiring improvement. No follow up actions were recorded nor ongoing plan to address shortfalls. The content of this spot check did not focus on all necessary areas of care. There was no evidence of how the management team obtained assurances their staff were competent and skilled to provide care.

Recruitment practices did not include all required pre-employment checks, including obtaining a full employment history and gaining evidence of conduct in previous relevant employment. The requirements of the regulations around recruitment were not understood by leaders.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff told us they had access to gloves, aprons and personal protective equipment to support safe provision of care. Records showed staff received IPC training and most staff confirmed this. However, current competency assessments did not include IPC to assure the management team, staff were competent with IPC practices.

One person lived with a potentially infectious condition. Their care plan included information about the condition, but did not provide information for staff to follow regarding reducing the risk of transmission to other vulnerable people.

We received mixed feedback from people regarding staff Infection Prevention Control (IPC) practices including handwashing and changing gloves between tasks not being completed after personal care provision. One person told us, “They [staff] do not follow the handwashing protocol and in fact do not change their gloves after personal care.”

This meant we were not assured infection prevention control practices were safe and effective. We discussed this with the registered manager who said they would review their systems and processes and make any necessary changes

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

The provider had failed to ensure robust systems were in place to ensure people received their medicines as prescribed. For example, one person received four visits a day and required medicines support from staff, however due to people not being allocated a specific time for a call, the system was not effective to ensure adequate time in between medicines being given as prescribed.

People’s care plans were not always consistent regarding medicines instructions for staff to follow, including protocols for ‘as required’ (PRN) medicines. For example, one person’s care plan stated, “Client administers own medication”, and later stated, “Carers to dissolve 2 co-codomol if required.” This was contradictory and unclear, and there was no protocol in place for this ‘as required’ medicine. Guidance to support the use of PRN medicines is important to ensure staff know when to give these medicines, the maximum dose to be given and the safe gap between doses.

People who were prescribed cream to maintain good skin integrity, did not have effective PRN protocols and body maps to record application in place. Risk management plans were not in place for people who were prescribed high risk medicines. For example, some people were prescribed blood thinning medicines and there was no risk management plan in place which was person centred, effectively mitigated and managed any risk and information was not regularly reviewed and updated.

We requested medicines records during the inspection which were not submitted. We discussed this with the registered manager and the compliance manager who said they would submit medicines administration records (MARS) for 5 people we identified. The requested records were not submitted, therefore we were not assured effective medicines systems and records were in place.

We asked for records of staff medicines training and competency assessments for medicines administration. We received one overarching competency assessment which was not specific for medicines administration and there was not an overarching training matrix to demonstrate if all staff were suitably trained.