Angels Care At Home Ltd

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 good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment, fit and proper persons employed, need for consent and staffing.

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

People told us they felt comfortable raising concerns about the service and felt listened to by some of the office staff. However, where people had raised concerns with the registered manager about missed, early or late visits they felt they had not been listened to, and nothing had changed.

When incidents or accidents happened, the provider did not always fully investigate. Staff were not always aware of incidents which occurred in the service to ensure lessons were learnt. The registered manager told us when incidents or accidents occurred, they would send an email to staff, but they did not follow up to ensure staff had read the email or to confirm if learning had taken place. They told us they would consider how they cascaded information about incidents and accidents in the future to ensure staff had the “confidence and understood the importance of getting things right.”

However, there was evidence of some incidents being recorded and the actions taken.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There was a system in place to receive referrals from a local authority and information was received on each person and their support needs. The provider completed a home visit to assess people’s needs. People told us their support went smoothly when they received support from the service.

However, the provider did not have any information available such as a hospital passport to ensure safe transitions for people when they went into hospital. Best practice guidance highlights the importance of hospital passports being in place. The registered manager told us they would start to implement hospital passports.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately.

Some incidents had not been recognised as potential safeguarding concerns. For example, we saw an incident where a staff member had not identified or responded appropriately to a person who was unwell and required medical assistance. Family members had to take action and called emergency service. Another incident involved family members raising concerns about a staff members medicine handling. Although some action had been taken by the provider to protect people from immediate harm, they had not referred some incidents to the relevant statutory bodies such as the local authority safeguarding team and CQC.

Some staff could not describe how they should support people who did not have capacity in line with the Mental Capacity Act. We spoke with 2 partners who supported a service user and they told us the person did not have capacity in relation to their personal care and finances. The registered manager told us on 2 separate occasions the person did have capacity in relation to their personal care. The service had not appropriately assessed the service users’ capacity in line with the Mental Capacity Act nor effectively liaised with partners to establish the information about their capacity.

Although there was a safeguarding policy it did not identify who the safeguarding lead was or contain the contact details for the local authority safeguarding team. Therefore, staff and service users did not have the relevant details about who to contact if there was a safeguarding concern.

However, people we spoke with told us they felt safe with staff and there was a safeguarding log available to record any safeguarding incidents. Staff were aware of the different types of abuse and how to escalate any safeguarding concerns.

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.

One person told us they had been requesting a copy of their relative’s care plan since they came out of hospital approximately 3 months ago. They told us they did not think staff had all the up-to-date information to meet the person’s needs. Another person told us they did not think staff would know what to do if their diagnosis escalated because staff lacked awareness about their condition.

We identified care plans and risk assessments did not always contain adequate information to support staff to manage people’s risks safety. For example, one care plan noted a person’s allergies, but it did not include sufficient information or guidance for staff on recognising symptoms associated with those allergies or the appropriate actions to take. Another person’s risk assessment had not been updated following a hospital admission, and there was conflicting information recorded about the history of pressure sores.

Records demonstrated 1 person who depended on visits for their nutrition and hydration needs to be met had 2 missed visits between August and September 2025. In 1 instance the provider had identified the missed visit and completed an incident form. However, the other missed visit had not been identified by the provider and when we showed them evidence, they said they were not aware. Other people also received care outside of their scheduled times. For example, between 01 October 2025 and 05 October 2025, we saw 3 examples of a person who received their lunchtime visits up to 2 hours earlier than scheduled. We also saw between 30 September 2025 and 09 October 2025, 4 examples where the same person received their afternoon visit up to 5 hours late. These inconsistencies in visit times may have placed the person at risk of harm due to delays or interruptions in care needs being met.

While care plans and risk assessments were in place and did identify some people’s risks and the actions staff should take, this was not applied consistently across the service. The registered manager acknowledged this gap and shared that one of their improvement priorities was to develop a central risk spreadsheet to consolidate all risk-related information in one accessible location.

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.

We identified there was no lone working risk assessment for a live-in staff member. There was no guidance for the live-in staff member regarding emergency procedures or the monitoring of smoke and carbon monoxide alarms. The registered manager informed us they routinely checked alarms and monitors were present in people’s homes, and staff were aware of their locations. However, there was no evidence available on documentation to show this. The provider could not assure themselves of the safety of both the person receiving care and the staff member, due to the absence of clear monitoring systems in place.

However, staff were able to describe the actions they would take in the event of an emergency, demonstrating an understanding of basic emergency procedures. There was a Business Continuity Plan (BCP) which identified what actions should be taken in the event of an emergency. The plan addressed how the service would identify and prioritise service users at high risk and included all key contact details.

People told us they had access to the equipment they needed, and staff demonstrated an understanding of how to manage risks associated with the equipment being used.

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

Overall, out of the 10 people we spoke with, 8 reported experiencing regular missed visits, visits occurring earlier or later than scheduled, or staff not staying for the full duration of their allocated time. These concerns were also corroborated through our review of scheduling records and daily care notes. One person told us, “There have been staffing issues for the last 3-4 months and over the last 4-5 weeks there have been no carers for at least 1 day a week.” Anotherperson told us, “Staff are supposed to stay for 1 hour, but they generally stay between 35-45 minutes.” Thisimpacted on people having their care needs met. The provider had tried to implement an effective system for missed visits after receiving contact from people using the service. However, we identified this was not consistently applied and some people still had missed visits.

The registered manager informed us recruitment had been a challenge for the service and confirmed addressing this issue was a current priority.

The provider did not organise regular team meetings for staff to receive service updates and contribute to ongoing improvements. This was confirmed by staff and the registered manager.

The provider had not ensured that a live-in staff member was receiving regular rest periods. The registered manager told us that due to staff shortages there had been 4 periods over the last 2 months where live-in staff had not received regular breaks. This meant live-in staff did not always have breaks to safeguard their wellbeing and maintain safe working practices.

Some staff recruitment checks were in line with legislation. However, the provider had not gained satisfactory evidence of pre-employment checks for 1 staffmember. For example, the staff member commenced in their role on 10 July 2025, and a reference was not provided by the previous employer until 07 October 2025. The provider had also not applied for an up-to-date Disclosure Barring Check (DBS) for this staff member. This meant the provider had not completed the required checks to ensure the person was suitable to work with vulnerable adults. However, they took steps to rectify this during the inspection.

Another staff member’s previous employment history listed on their application form, was inconsistent with the dates provided in a reference from a former employer. The provider had not identified this discrepancy nor taken steps to verify the accuracy of the employment dates with the staff member or previous employer. This indicated a lack of appropriate recruitment checks in line with legislation.

We requested a copy of staff training records. However, the documentation provided did not clearly indicate what training staff had received. As a result, we were unableto verify what training staff had or had not completed.

Despite gaps in the provider’s training records, staff told us they received regular training, support, and supervision, and felt able to contact the office for guidance when needed. We also reviewed evidence of staff supervisions and annual reviews.

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.

We reviewed documentation for one individual who had a potential transmissible infection. However, the provider had not identified or assessed the associated risks to staff or other people using the service. An infection prevention and control (IPC) policy was in place; however, it lacked key information, including the name of the person responsible for ordering and supplying personal protective equipment (PPE), and the designated individual for reporting IPC incidents.

However, people told us that staff consistently wore PPE and followed good hygiene and infection control practices. Staff also confirmed they had access to PPE and demonstrated a good understanding of infection prevention and control procedures.

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

For example, one person told us they had communicated with 3 different staff members regarding a change in their medicine. However, this change had not been documented in their care plan. As a result, there was a risk of staff not being aware of the updated medicine needs, potentially leading to unsafe medicines practices. There was no direct impact on the person because family were available to give staff the relevant information about medicines.

Another person told us staff visit times had impacted their ability to receive medicines on time, and they sometimes relied on family support. Review of medication administration records (MAR) showed missed entries for two people. For example, one person prescribed a high-risk medicine to prevent strokes had missing entries on 03, 04 and 05 October 2025. Another person had missing entries for four different medicines between 01 and 10 October 2025. The registered manager was unaware of these omissions and could not provide an explanation. This meant the service could not be assured that people had consistently received their medicines as prescribed. Where family were not available to assist, this could have placed people at significant risk of harm.

We also saw evidence of an incident where 1 person was not supported to take their high-risk medicine on 09 August 2025. Although no harm came to the person this potentially placed them at risk of harm. Additionally, risks had not been assessed for 2 people using emollient-based creams in relation to the fire hazards associated with using the product.

Although audits of medicines were taking place, these were not effective in identifying the concerns we found. The person delegated by the registered manager to complete the audits did not have the skills or the experience and competencies to understand what to look out for. The registered manager and nominated individual told us they had appointed another registered manager to join the service to provide the oversight needed.

However, staff received regular medicine competency checks and care plans included the support people required with medicines and the types of medicines people needed support with. As and when (PRN) protocols were in place and there were arrangements for the collection of people’s medicines which was documented in care plans.