Admiral Jellicoe House Also known as The Royal Naval Benevolent Trust

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed all quality statements within the effective key question. We identified a breach of regulation relating to consent. People’s needs had been assessed but care plans did not always include the latest guidance for staff. Staff told us they often relied on verbal information. This could place people at risk of harm and lead to inconsistencies in care and support. There was a lack of routine monitoring of people’s care and treatment to ensure positive and consistent outcomes. The lack of consistently updated information in people’s care records could impact on effective working across teams and services if incomplete or outdated information is pulled from the electronic system and shared. While people felt their rights and decisions were respected, we found consent to care and treatment was not always sought in line with the law and guidance. People gave mixed feedback about the food available within the service. The provider was working with a catering consultant to improve people’s food and catering experience. However, people were supported to manage their health and wellbeing so they could maximise their independence, choice and control. People and relatives reported improvements in health and wellbeing since admission to the service. Staff used current evidence-based and good practice standards to plan and deliver people’s care and treatment with them. The service was working closely with external professionals to make improvements to the quality and safety of the service.

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.

We received mixed feedback from people and relatives about needs assessment. Some relatives told us they had not seen their relation’s care plan or been involved in reviewing their needs and support. This is important when people are unable to give information and /or make decisions independently. Their comments included, “I have not seen a care plan for Mum, and I raised this at the residents meeting, but I have still not seen one”, “I haven't seen a care plan not talked about future planning” and “We wrote the care plan, but I have not been involved in a review although there have been changes.” Before a person moved to the service, their needs were assessed. This information was used to develop care plans. One person told us, “They talked about my care needs initially and I also get monthly blood pressure, weight, and oxygen checks. They always discuss what you need with you and your family.”

Staff gave mixed feedback about the availability of up to date and comprehensive needs assessments. Some staff told us they relied on verbal information from each other, because information was not up to date, or it was difficult to access the information on the electronic system. We found staff were knowledgeable about people’s needs, however, lack of comprehensive and up to date guidance can impact on the consistency of care people receive. The registered manager told us they were introducing a ‘resident of the day’ system. This involves a schedule to review specific people’s care plans on each day of the month. She told us this would involve people and, where they wished, their relatives or representatives to ensure the care plan was comprehensive and up to date.

The registered manager and senior care staff carried out initial needs assessments. Assessments included the use of nationally recognised tools to assess needs and risks in areas including skin integrity and nutrition. We noted referrals to other professionals such as the Speech and Language Therapists or Mental Health Teams had been made appropriately. NEWS (National Early Warning Score) was used to assess clinical deterioration and to guide staffing in making appropriate referrals for support including if necessary to paramedics. Whilst care plans contained person-centred information about the individual, not all care plans we reviewed were up to date to reflect people’s changed needs and risks. We have covered this in the safe section of this report. Whilst tools were in place to support the application of the Mental Capacity Act (MCA) these were not always used. We have covered this in the effective question in our findings about consent. People’s protected characteristics were explored as part of the assessment, except for sexual orientation. Asking people about this helps providers consider the full range of people’s diverse needs and promote an inclusive environment.

People gave mixed feedback about the food available. One person told us, “The food is up and down, sometimes I just can’t eat it, but they do offer me something else. Sometimes it is over cooked, and it is not ‘fine dining’.” Another said, “The food is reasonable but could be better.” A third told us, “The food is good, and they are very good… the kitchen staff give me a weekly menu and I cross out what I can’t eat, and I give them suggestions and they are happy to do it.” At the time of the assessment a catering consultant was working in the service to improve people’s food and catering experience.

The registered manager was aware improvements were required in catering and work was underway to address people’s concerns. Staff we spoke with were aware of people’s needs in relation to the consistency of their diet which had been assessed by external healthcare professionals using a recognised tool. Fluid intake for people at risk of poor hydration was recorded by staff, with a nominated staff member responsible for this on each shift.

Care plans identified people’s needs in relation to nutrition and hydration. However, risk assessments were not always comprehensive to show target fluids and an evaluation of intake. There was a lack of clinical oversight of people’s fluid intake because their records were not evaluated to ensure they were drinking enough to meet their needs. Evidence based good practice standards were used to assess and deliver appropriate care. Assessments included the use of nationally recognised tools to assess needs and risks in areas including skin integrity and nutrition. People at risk of malnutrition were monitored at daily clinical risk meetings. The chef attended these meetings so higher calorie food and snacks were prepared for individuals as required.

People reported their needs were met by staff. Some relatives told us they had concerns about communication between staff. One relative said, “You can tell somebody (staff), but you never know if everyone knew.”

The registered manager was aware communication between teams in the service could be improved and was working with the leadership team to support effective communication and information sharing. Staff reported communication between teams in the service could be improved. One staff member said, “Only senior has handover sheet, would be good for us all to have one.” Another staff member told us, “Communication is not great in certain areas, we are not kept up to date on changes. We don’t have time to read documentation when things have changed.” A third explained how notes could be made on the electronic system so they flagged up at handover.

There had been increased support from external professionals working with the service following safeguarding concerns being raised. This included adult social services, the care homes team, a medicines optimisation technician and an infection prevention and control specialist. Professionals reported the provider has engaged positively with visiting teams to make improvements in delivering effective care and treatment.

Information about people’s needs was shared at daily clinical risk meeting and staff handover. However, we found information was not always consistently recorded to support effective care when other services were involved. The care plan system allowed for summaries to be produced to assist information sharing between services. We found care plans did not always include the most up to date information about a person’s health and needs. Reliable information in the electronic records would be required to ensure this information sharing was effective.

People and relatives gave positive feedback about how people were supported to live healthier lives. A relative said, "Dad’s health is the best it's been in years, and he is more mobile. He has had one fall since being here, but he used to fall regularly at home. Staff immediately rang me and told me when he fell, they said what had happened and what they had done, I think that's really good." Another relative said, “They asked the Mental Health Nurse to come in last week to adjust his medication as he is always sleepy.” We saw examples of how people had been supported with physiotherapy and using the gym to improve their strength and mobility. Records demonstrated people were seen by the GP and other healthcare professionals when needed.

The registered manager told us how daily clinical risk meetings were used to identify the support people needed with health issues. The registered manager promoted a culture of supporting people to maximise their independence to support their wellbeing. We discussed examples of how people were supported to retain control of what they could do for themselves, such as decide what support they needed with eating. A person had been encouraged to garden which supported their physical and mental wellbeing. Staff described how they supported people to maintain their independence with walking for example by encouraging the use of mobility aids and assisting “where needed.” Staff knew people well and told us they felt confident they would identify if a person’s health was deteriorating. They said they would report any concerns to the nursing team.

People’s care plans described their planned outcomes and how these were to be achieved in relation to their health and wellbeing. This included physical and mental health. Reviews did not always show progress against outcomes, however, records confirmed people were referred to external agencies as needed to receive the health support they required. Daily clinical risk meetings were used to share information on people’s current health status such as wounds, nutrition scores and infections. This included concerns from care staff when people’s health was thought to be deteriorating. Appointments and referrals needed were also identified at this meeting.

People and relatives told us care and treatment at the service had resulted in improved outcomes for people. A person said, “I haven't had any falls since I have been here. I do feel very safe here much better than when I was at home.” A relative shared, “The staff put in place a plan to mobilise [relative] which was very good.”

The registered manager told us the service had not had a clinical lead in post which had led to a lack of consistency in clinical leadership. As a result, systems to monitor risk and clinical outcomes, such as bowel monitoring, had not been consistent or fully embedded. The registered manager told us, “Now [a clinical lead has been appointed] they can check processes are embedded and promote accountability.” We discussed examples of how people had been supported to achieve desired outcomes such as a person who wanted to focus on walking again, which they achieved.

Care plan reviews of planned outcomes did not always give detail about progress or evaluation. People’s care plans did not always show progress or evaluation of clinical outcomes in relation to wounds. Whilst nurses kept records of wound reviews there was no care plan in place to detail care, treatment and evaluation. Body maps used by staff to record skin injuries did not show progress with treatment. Whilst records did confirm people were receiving treatment, information was not accessible to guide staff on treatment and effectiveness of that treatment. The registered manager used information collected against quality indicators to monitor clinical outcomes. This included infection rates, pressure sores, safeguarding incidents, malnutrition scores and medication errors. This did not currently include a trend analysis which would help to inform improvements. For example, falls and infections had shown they were over the provider’s acceptable level but there was no analysis to show factors which may have caused this. This analysis helps providers to identify preventative strategies and drive improvement.

People who were able to tell us about their experience said their decisions were respected by staff. One person told us, “I have control over what I want to do.” Another said, “I am fully in charge of my own space and if I wanted something it would happen.” A third said, “It's good because I am not forced to do anything.” A relative told us how their relative, “Sometimes likes to have a ‘Duvet Day’ and the staff respect this.” A person who lacked mental capacity was supported by an Independent Mental Capacity Advocate (IMCA) who had been involved in supporting them to make decisions.

Staff we spoke with showed an awareness of the mental capacity act and how to apply the principles in their work. Staff explained how they supported people to be involved in their care and make decisions. One staff member said, "I always assume capacity and would involve people in decisions." They went on to tell us how they supported people who couldn’t verbally express choices and how using knowledge of people helped to offer specific choices to prevent them becoming overwhelmed with choice.

Consent to care and treatment was not always sought in line with law and guidance. Care plans included information on people’s ability to make decisions and how they could be supported to make decisions, such as giving time for people to process information and keeping choices simple. However, care plans did not always include information about mental capacity assessments and best interest decisions to evidence the Mental Capacity Act 2005 (MCA) had been followed. People who had the capacity to consent to decisions were asked to sign forms to consent to care, support with their medicines and information sharing. Where people lacked capacity to give their consent in these areas, assessments had not always been completed and records were not available to demonstrate decisions had been made in their best interests. Processes to support decision making under the Mental Capacity Act were not always followed correctly. For example, people’s capacity to agree to the use of a movement sensor mat, which is considered a restriction, had not always been assessed or documented. The registered manager acknowledged consent had not always been sought and evidenced in line with the MCA. The failure to act consistently in accordance with the MCA was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.