Angels Care At Home Ltd

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.

This service scored 54 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The values, mission and vision were documented in the services statement of purpose and in the handbook given to people when they started using the service. The registered manager had focussed on recruiting experienced health and social care staff and had plans in place for the direction of the service in the future.

Staff who were new to the service told us they felt welcomed by the registered manager and the rest of the team and overall staff said they enjoyed working for the service.

However, staff were not always aware of the values and vision of the service. One staff member told us, “I don’t think they have any.” However, another staff member told us the values were, “Make sure clients are looked after and safe.” The registered manager told us they could not remember when the values were last discussed with staff, but they received a copy of the information when they first commenced in their role. The information was also available to people in the handbook which was provided when they started support.

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.

The registered manager did not always have oversight of the service and had delegated tasks, such as being on call for any staff queries, completing medicines competencies and audits to another staff member. However, the staff member did not have any training or qualifications in Health and Social Care. We identified one occasions when the person delegated by the registered manager had made a decision which resulted in a person not being supported to take their high-risk medicine to prevent a risk of stroke.

We found some of the audits being completed had not identified some of the concerns we found in relation to people’s care plans and risk assessments. There were some potential incidents which the provider had not reported to the relevant statutory agencies.

However, people and staff told us they liked the registered manager, they felt supported but sometimes could not get in contact with them. One staff member provided an example, where the registered manager had supported them with a personal issue and told us, “[Manager] gave great support.”

We found the registered manager to be open and honest about the service challenges and their plans to step back from the role and recruit a more suitably qualified person. The newly appointed registered manager was due to commence in their role in December 2025.

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Staff told us they were able to speak up during supervisions. We reviewed evidence of supervisions and annual reviews where staff had been able to have their voices heard. Staff told us they were able to approach leaders, and they were supportive, although they said the registered manager was difficult to get hold of at times. There was a whistleblowing policy in place.

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.

There were workforce equality, diversity and inclusion (EDI) polices in place and staff told us they had not experienced any discrimination towards them. Staff were positive about EDI in the service. There was evidence of staff completing a health questionnaire when they commenced in their role and at the time of the inspection no staff needed support with reasonable adjustments.

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.

Although audits were being regularly completed, they failed to identify some areas of concern. For example, the concerns in relation to gaps in medicines administration records (MAR), care plans, risk assessments and recruitment practices. We saw gaps in 2 people’s MAR charts which meant the provider could not be assured people had received their medicines in line with their assessed needs.

Care plans and risk assessments lacked detailed information for staff to support people with specific diagnoses or allergies. This placed people at risk because staff did not have access to the relevant information to support people safely.

The provider failed to implement an effective system to track if people had early or late visits, missed visits or whether staff stayed for the full duration of their scheduled visits. This meant there was a lack of consistent care delivery for people.

Recruitment practices were not always in line with legislation. We identified a DBS had not been obtained for a new staff member and a reference was not sought until 3 months after they commenced in their role. This meant the provider had not completed the required checks to ensure the person was suitable to work with vulnerable adults.

Systems failed to identify potential safeguarding concerns, and although internal actions were taken, they were not referred to the relevant statutory bodies as required. The consent processes in place meant the provider did not assess the capacity of 1 service user in line with the Mental Capacity Act (MCA).

Policies did not always contain relevant information. For example, the safeguarding policy did not state who the safeguarding lead was within the company, and the contact details for the local authority were not available. Additionally, the IPC policy did not state who was responsible for ordering PPE and who staff should report IPC incidents to. Some polices were not in place. For example, when we requested a copy of the live-in care policy, they did not provide it.

However, there was evidence of regular audits being completed which had identified and rectified some concerns. Several policies were available which were comprehensive and adequate for their intended purpose. For example, the bullying in the workplace policy and equal opportunities policy.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for

improvement. We saw evidence of where the provider had worked with other partners on behalf of people they supported such as Occupation Therapists and Doctors.

Where people had been assessed as needing access to the community as part of their support plan, staff were escorting and attending community-based events with people.

However, partners told us the communication with the service was difficult at times and they did not always receive a timely response to their telephone calls or emails. They told us they mostly had to chase up information.

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

The registered manager told us they did not have regular team meetings with staff, although there was evidence of regular leader meetings taking place. They also said they had not attended any recent local authority meetings, but this would be on the agenda for the new registered manager when they commenced in their role.

Lessons had not been learned since the last inspection in relation to the embedding of governance and quality assurance systems and processes.

However, the provider was responsive to our assessment and saw it as an opportunity to start afresh and help identify areas they needed to focus on. They wanted to design some new processes where they had identified changes needed to be made.

Where people had raised complaints there was a system to record the complaints and the actions and outcomes.