Admiral Jellicoe House Also known as The Royal Naval Benevolent Trust

Updated 3 January 2024

Date of assessment 17 January to 14 March 2024. This assessment was completed following concerns received regarding medication, staffing, care plans/documentation, communication and incidents between people using the service. We carried out an assessment of the service including site visits on 17, 22 and 31 January and 25 February 2024. The team included 4 inspectors, a member of the medicines team and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. This was the first assessment of this newly registered service. We identified 5 breaches of regulation relating to safe care and treatment, consent, staffing, good governance and notification of incidents. Improvement was needed to ensure risks to people are identified and mitigated. Staff lacked reliable information to guide safe practice. There was a lack of routine monitoring to ensure positive and consistent outcomes for people. While people felt their rights and decisions were respected, consent to care and treatment was not always sought in line with the law and guidance. Staff reported feeling unsupported and had not received regular supervision. We found gaps in governance which resulted in risks either not being identified or not being addressed in a timely manner. The service had failed to notify the Commission of specified incidents. Learning from incidents was not consistently shared to embed good practices. The service had been through an unsettled period of leadership change from October 2023. Since our visit, a new leadership team, including a registered manager, has been appointed. Staff respected people’s privacy and dignity and treated them as individuals. Staff responded quickly to meet people’s needs. We observed people were engaged and able to pursue their own interests and choices. We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 3 January 2024

People spoke highly of the service. They told us staff were kind and treated them with dignity and respect. One person said, “They are compassionate, kind, empathetic and are quite prepared to give you the time”. Another told us, “I feel like royalty living here.” People told us staff knew them well and understood how they liked to be supported. They told us they had control over how they wished to spend their time and were supported to be independent. They told us they enjoyed the variety of social activities and events on offer. They told us there were enough staff on duty to meet their needs. People spoke positively about the home environment and cleanliness. One person said, “I think it is just such a lovely, wonderful place.” They told us they felt safe, well-supported and had confidence any concerns they raised would be addressed. One person shared, “I know that whatever happens there is someone here that can help me.” People gave mixed feedback about the meals in the service, with most indicating they would like to see improvements in this area. While the people we spoke to expressed they were happy with their care, our assessment found elements of care did not meet the expected standards. This was in relation to identifying and mitigating risk, following legal process to ensure people’s rights are respected, supporting staff and ensuring effective oversight of the service.