Admiral Jellicoe House Also known as The Royal Naval Benevolent Trust

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

We assessed one quality statement within the well-led key question. We identified two breaches of regulations relating to good governance and notification of other incidents. The service had been through an unsettled period of leadership change since October 2023. We found gaps in governance and oversight which resulted in risks either not being identified or not being addressed in a timely manner. This placed people at risk of potential harm. The service had failed to notify the Commission of specified incidents that occurred in the service. Whilst action had been taken to notify the local authority safeguarding team and to mitigate future risk, this is a legal requirement. Since our visit, a new leadership team has been appointed, including a registered manager, operations manager, clinical lead and deputy manager. The leadership team have been responsive to the areas of concern identified during our assessment and those highlighted by other partners. Where staff had been feeling unsettled by the changes and unsupported due to a lack of consistent leadership and supervision, recent reports indicate staff felt their views had been listened to in meetings.

This service scored 7 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Prior to the inspection there had been changes in the leadership team. This included the recent departure of a registered manager, deputy manager and clinical lead. At the time of the inspection a new leadership team had been recruited. Whilst action had been taken to provide interim leaders, the lack of a consistent team had impacted on the quality assurance processes in the service. We received mixed feedback from staff about their confidence in the leadership of the service. This had been impacted by the leadership changes which some staff felt had not been communicated well. The registered manager told us the lack of clinical leadership had resulted inconsistencies within the nursing team which was now being addressed. On the final day of our site visit, staff reported meetings had taken place with the registered manager and nominated individual. Most staff we spoke with told us these had been positive, they felt listened to and reassured.

Governance and performance management systems were not always reliable and effective. Risk had not always been identified, managed or mitigated in a timely way. Guidance for staff on how to meet people’s needs and mitigate risks in their care had not always been updated. The service had failed to identify gaps in how the Mental Capacity Act 2005 (MCA) had been applied and that some DoLS applications were out of date. The service had a quality improvement plan. This showed progress had been slow, which meant identified risks had not been addressed promptly. For example, shortfalls in care plan reviews had been identified in September 2023 but had not been sufficiently addressed. Bimonthly information on quality and safety standards was not analysed for trends and did not identify improvement actions, despite several areas falling below the provider’s acceptable standard. The lack of effective systems to assess, monitor and improve the quality and safety of the service placed people at risk of potential harm. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered manager had been supported by the nominated individual to address shortfalls in the service. They were working alongside external professionals to develop systems and practice in the service to deliver safe and effective care. The registered person must notify the CQC without delay of specified incidents that occur in the service. We found 13 reportable incidents had not been notified to CQC as required. The failure to notify the Commission without delay of incidents that occurred whilst carrying on a regulated activity was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.