Admiral Jellicoe House Also known as The Royal Naval Benevolent Trust

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

We assessed all quality statements within the safe key question. We identified two breaches of regulations relating to safe care and treatment and staffing. Risks to people's health and safety had not always been identified and guidance for staff on how to mitigate them was not always available. People did not always have updated care plans to guide safe practice. Learning from incidents was not consistently recorded or shared with the staff team to raise awareness of risk and embed good practices. People may have been subject to unlawful restrictions because processes to support decision making under the Mental Capacity Act 2005 (MCA) were not always followed correctly. Staff had not received supervision in line with the provider’s policy and they reported feeling unsupported at times. Clearer guidance was required for staff to support the safe administration of medicines, for example medicines prescribed on a when required basis or with a variable dose. However, there were enough staff to ensure people’s safety and meet their needs. Staff understood their responsibilities under safeguarding and worked to protect people from abuse and improper treatment. The premises were of a high standard with facilities, equipment and technology supporting the delivery of safe care. Systems were in place to provide a clean environment and to detect and control the risk of infection. The service was working closely with system partners to establish and maintain safe systems of care and to ensure continuity of care when people move between different services.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives gave positive examples of how the service had responded to incidents and complaints. One person said, “I know that if I saw something not right, it would be sorted.” A relative shared how they had been informed and kept updated regarding an incident that occurred. They described the actions the service had taken to minimise future risk. They told us, “They carried out the plan and it worked, which I am very happy about.”

We saw examples of learning from incidents being shared with the staff team, either by email or by displaying a poster. The records in place did not demonstrate this was consistent practice. Some incidents had not been signed off and actions were not always recorded. People’s care records had not always been updated following incidents. As staff did not always have updated guidance on how to support individuals and minimise risk, this could lead to inconsistent care or similar incidents occurring.

Processes were in place to identify, investigate and report safety concerns. We found, however, records did not demonstrate learning had been consistently identified and acted upon to make improvements. For example, people’s care plans had not always been updated to show the actions taken in response to incidents such as falls. Whilst data relating to incidents was available, this had not been analysed to identify trends and possible areas of improvement. Where improvements had been identified, these were acted upon. We saw the service had worked effectively with system partners, including adult social care and the integrated care board, to act on their recommendations. The service was overseen by a Board of Trustees and Chief Executive Officer with a governance strategy in place, including a values framework. The service reported against quality performance indicators to the board monthly and a care and safeguarding committee was held termly to review issues and risk.

People and relatives told us they received the care and treatment they needed, including by referral to other health and social care professionals.

Staff described how they raised concerns with the senior staff, nurses, and managers. The registered manager told us how they worked with other health and social care professionals to meet people’s needs. This included nurses from the care homes’ team, Speech and Language Therapists (SaLT), older people’s mental health team and occupational therapists. Following an initial assessment, nurses called emergency services when needed so people received hospital treatment if this was required. Staff told us any health issues requiring GP assessment were discussed in the daily clinical risk meeting.

At the time of this assessment, the service was working with system partners to strengthen and maintain safe systems and pathways. This included the local authority safeguarding team, care homes team, adult social care team and commissioners.

When a person moved between services, 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. There was information in people’s care records that demonstrated advice and guidance had been sought from other health and social care professionals.

Most people and relatives told us they, or their relative felt safe living at the service. People’s comments included, “I know that whatever happens there is someone here that can help me” and, “I feel free to do what I like, and I do feel safe.” A small number of individual concerns were raised by people and their relatives. These were addressed with senior staff during our assessment.

Whilst the registered manager understood their responsibilities under safeguarding to report incidents and allegations of abuse to the local authority, our conversation indicated they had not fully understood the requirement to notify the Commission. Staff we spoke with understood their safeguarding responsibilities and how to report incidents or concerns. A staff member said, “I would report any concerns to the shift leader or the manager. If I thought it was not being looked into properly, I would report to area manager, local authority or CQC.” Staff told us they knew who in their care was subject to Deprivation of Liberty Safeguards (DoLS) and what this meant. Staff described supporting people with choices and decisions and the process of best interest decision making when required.

We observed people received safe care. People were treated respectfully by staff and people spoke positively about their experience of care.

Processes to support people’s rights and safety were not always completed. The registered manager had reported safeguarding concerns to the local authority. Whilst we found concerns had been acted on, safeguarding incidents had not always been notified to the Commission as required. The regulations state what a provider must notify us about when there is a change, event or incident in a service. This is important so when needed the Commission can take action to help keep people safe. We have addressed this in the well led section of this report. Processes to support decision making under the Mental Capacity Act 2005 (MCA) 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. Some authorised Deprivation of Liberty Safeguards had expired at the time of our first visit to the service. This meant people were unlawfully restricted. The registered manager took immediate action to address this by renewing the applications. Staff had completed training in the MCA and DoLS.

People and relatives gave mostly positive feedback about feeling safe and well cared for. People’s comments included, “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 told us, "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." Some relatives raised concerns that information about risks in people’s care was not always shared adequately between staff. They said this resulted in inconsistency.

Staff told us they relied mostly on shadowing colleagues and verbal information to understand people’s needs and how they liked to be supported. They were sometimes unable to confirm if their approach matched the written guidance in the person’s care plan and risk assessments. Some staff told us they found the information in care plans difficult to follow. Whilst staff demonstrated an awareness of people’s needs and the risks in their care, the fact they did not routinely refer to people’s care plan could lead to inconsistency of care or important changes being missed. Gaps or ambiguity in care documentation could put people at risk when new or temporary staff were supporting them. Some people in the home could become distressed, posing a risk to themselves and others. Staff told us they would welcome training in how to support people to minimise distressed behaviour. The registered manager told us communication between staff at handovers needed to be improved and explained the action they were taking. This included updates to people’s care records to ensure staff had reliable, clear and updated information to refer to.

During our visits, we observed people being supported safely by staff. For example, we saw people being supported to move using equipment. This was done safely with involvement and reassurance given to the person being supported to transfer.

The processes in place to manage and communicate risk were not robust. We found gaps and inaccuracies in records which put people at risk of receiving inconsistent care. Actions to mitigate risk, such as regular repositioning to reduce the risk of pressure areas or bowel monitoring to identify if a person was at increased risk of constipation were not routinely completed. Guidance for people whose support varied lacked detail, for example staff told us they knew how much thickener to use in a person’s drinks by “getting to know” them. Information on some known risks, such as distressed behaviour, was missing from people’s care plans meaning staff did not have guidance on how best to support the person. It was not evident risk management actions resulting from incidents of distressed behaviour were identified or updated. The service collated information about incidents and this included falls. It was not always evident from the records that individual risks had been reviewed following incidents. We found incident data and information had not been analysed to see if any trends could be identified. Identifying patterns, such as falls occurring at a certain time of day or in a particular part of the home, may help establish preventative measures. Whilst information was shared via the system, we were not assured all staff received the information and updates in a timely way to enable them to support people consistently and safely. Personal Emergency Evacuation Plans (PEEPs) were in place to provide information for staff and emergency services in the event of evacuating the premises. Not all PEEPs had been fully completed to detail equipment or assistance people required to mobilise. We spoke with the registered manager about this. They confirmed they would take action to address these gaps. The failure to assess and mitigate risks in people’s care was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People and relatives told us the environment was safe, appropriate to their needs and of a high standard. A person said, “I think it is just such a lovely, wonderful place. I looked at 10 homes before choosing this one.”

Staff knew how to report any concerns relating to the environment. They had completed training in fire safety and health and safety to support them to identify any risks. Leaders explained the checks, audits and testing that was in place to promote a safe environment and safe equipment.

We observed premises were of a high standard, clean and in good decorative order with some exceptional features such as the interactive dementia friendly boat, cinema, and media to support and engage people living with dementia. We noted some improvements could be made to improve the accessibility of the environment for people living with dementia such as stronger contrasts in colour on handrails, door colour, signage, and toilet seats. We shared this feedback with the provider.

Processes were in place to ensure regular checks of the premises and equipment, including fire safety and Legionella checks and checks on equipment used in care such as hoists. A process was in place for staff to report any identified concerns with the environment for the maintenance team to address.

Most people and relatives told us they were satisfied with the staffing level. Their comments included, “I think there is mostly enough staff” and, “yes definitely, I always get the support I need when I need it. The staff come fairly quickly if I ring my bell.” Some feedback included examples of times when staffing had dropped below the planned level or where they had been a higher number of agency staff. People confirmed their needs continued to be met but said this had an impact on their preferences, such as the time they received care. Overall, we found there were enough staff to meet people’s needs.

Staff told us they had not received regular supervision and had missed this support. One staff member told us, “Supervisions aren’t frequent enough”. Another said, “I think I had 2 in 2022.” Some staff told us they did not feel confident to support people with distressed behaviours and required further training and support. The registered manager told us that the lack of a clinical lead had impacted on cohesion and consistency with the clinical team. A member of the clinical team told us they needed “A capable and confident clinical lead.” At the time of the inspection a new clinical lead had been appointed. We received mixed feedback from staff regarding staffing levels. Staff comments included, “I think there is enough staff, it can have busy times, but overall, we have enough time to support people” and, "I do feel there is enough of us, we work well together and do have time to spend with people." “Current staffing is okay, when short staffed it is not being able to be with them [people] and preventing emotional distress.” Staff we spoke with told us about how they worked together to ensure people’s needs were met when unplanned absence occurred. One staff member said, “I wouldn’t say it was unsafe the floor runs better when there are 6 on the floor. I wouldn’t say the care for the residents gets missed.” The registered manager and director of operations acknowledged there had been periods of lower staffing and agency staff use when unplanned staff absence had been high. However, at the time of the inspection the home had successfully recruited to staff vacancies and the staffing level was consistent with the levels calculated to meet people’s needs. The registered manager was working with staff to identify improvements in staff deployment to best meet people’s needs.

Throughout our onsite visits staff were responsive to people’s needs and supported people in a timely and kind manner. Call bells were answered promptly.

Staff supervision had not been carried out inline with the provider’s policy (every 2 months). Staff supervision is important to make sure staff competence is maintained to carry out their role. Records of supervision showed 50% of the provider’s staff had not received supervision in line with the policy. The registered manager confirmed there was a plan in place to address supervision shortfalls. Staff training records showed not all staff had completed training in line with the provider’s mandatory training requirements. Shortfalls in staff training had been identified in September 2023 on the quality improvement action plan, some improvement had been made but completion rates remained below the provider’s standards at the time of this assessment. The failure to provide staff with appropriate support, training and supervision impacted on their abilities to carry out their duties. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Employment records did not always include a staff member’s full employment history. This information is important to support safe recruitment. The registered manager was acting to address this. A staffing dependency tool was used to calculate the number of staff required to support people’s needs. In the staffing rotas we reviewed the staffing levels were as planned.

People and relatives told us the home was clean. A relative said, “The home always looks very clean.” A person told us, “The rooms are cleaned every day.” Another person said, “They are very good as when there is Covid [COVID-19] around they [wear] masks and at other times too.”

The registered manager described how they had managed an outbreak of infection in the home. The home had subsequently received support from an infection prevention and control specialist from the integrated care board. Recommendations they made had been incorporated into the service improvement plan. Care and housekeeping staff were able to explain how they minimised the spread of infection. One member of the team said, “Keeping myself clean and wearing PPE. Cleaning hands, using hand gel. Sorting out soiled clothing into red bags when needed. Sluice clean, spillages cleaned up and inform housekeeping if needed.”

The home was clean and in good repair. Where we identified an issue with carpet that smelt strongly of urine, this was promptly addressed by replacing the carpet with an easy to clean floor covering.

Policies and procedures were in place to guide staff on safe practice in infection prevention and control. Staff had completed training in IPC and food hygiene. We noted the provider’s monthly IPC audit had not been completed in the two months prior to our assessment. Actions identified through earlier audits had been addressed to promote people’s safety and a clean environment. The registered manager told us a new IPC lead had been appointed and explained they would complete the audits.

People told us they received regular support with their medicines. Where assessed as competent to do so safely, people were supported to manage their medicines independently.

Staff were able to describe how they supported people with their medicines. Our conversations with staff identified gaps in the guidance available to them and inconsistencies in how topical creams were recorded. Where people were prescribed medicines on a when required basis or with a variable dose, there was not always sufficient detail at the point of administration for staff to ensure consistency of approach.

Audits of medication had not identified some of the issues identified during our assessment, for example there were gaps in fridge temperature records, a liquid medicine was found to have expired and a person who was self-medicating was not storing their medicine in line with the risk assessment. Clearer guidance was required for staff at the point of administration, for example medicines prescribed on a when required basis or with a variable dose. We identified the quantity of controlled drugs denatured was not always recorded and that the provider did not have a T28 waste exemption certificate. The failure to ensure the proper and safe management of medicines was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.