Admiral Jellicoe House Also known as The Royal Naval Benevolent Trust

During an assessment under our new approach

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.

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