Admiral Care Limited

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 requires improvement. At this assessment the rating has remained 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 good governance and notifying CQC of incidents.

This service scored 43 (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 did not offer opportunities for staff to discuss organisational values and culture. The provider told us they had not held a staff meeting in over a year and there was no system of regular support sessions to ensure the provider could share their vision for the service.

We asked staff members what the vision and values of the service were, comments included, “I can’t remember,” and “Not off the top of my head.”

Whilst there were policies in place, people were not supported to know their rights, to be involved and engaged in their care and their individual rights were not always upheld

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 provider did not demonstrate sufficient understanding of their regulatory responsibilities, including the statutory notifications they were required to submit to CQC. This lack of regulatory awareness contributed to poor management oversight and reduced assurance the service was operating in line with regulatory requirements.

One staff member told us, “I’ve had one spot-check, I don’t think it’s a regular thing,” another said when we asked if they felt supported by leaders, “The ones I get in contact with, I suppose,” and “Depends who you talk to.” This demonstrated not all staff felt supported by leaders

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

The provider had a whistleblowing policy in place and staff confirmed they knew how to access this. The registered manager told us they would support staff to raise concerns, and challenge unsafe any unsafe practice they witnessed.

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 provider had policies and procedures in place relating to equality, diversity and inclusion. Staff told us they felt fairly treated at work and their human rights were upheld.

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.

Records were not maintained to be accurate and complete in relation to people using the service. Care plans did not reflect people’s needs and had no process for regular updates. Records related to the running of the service were not maintained or complete, including recruitment records, audits of the quality of care, systems for ensuring care calls were complete and timely, incidents reported and investigated and complaints.

Systems and processes for oversight of the service provided were not robust or effective and concerns identified during inspection had not been identified by internal systems. Audits were inadequate and did not identify concerns in relation to assessing and managing risks, obtaining consent and assessing capacity, recruitment practices, incident reporting and management of complaints.

In addition, no effective system was in place to prompt staff supervisions which their policy stated should occur four times a year and maintain oversight of staff competencies and training. This contributed to failure to maintain safe oversight and governance of the service

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

We received mixed feedback from professionals about the service and how they worked together, including communication with the service. Care plans for people did not always identify other professionals working with them, how the care for that person was shared across services, and how and when to escalate to professionals.

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

While most people or relatives we spoke to knew who the manager was, the provider did not have a system for gaining and using feedback from people, staff or professionals to drive improvements in the service. All people and relatives we spoke with told us they had not been asked for feedback about the care provision.

There was no quality improvement plan or development plan for the service, and no system to identify areas for improvement, development, learning or innovation. People’s experience and outcomes were not monitored or measured to help shape services to meet their needs.