Admirals Reach Care Home

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

Systems and processes were in place to keep people safe, and risks associated with people's care needs had been assessed. There were sufficient staff to meet people's needs and recruitment processes and procedures were robust. Medicines were managed safely.

This service scored 75 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people including informing other agencies if they were concerned about action being taken. A staff member told us, “I would report to whoever is in charge. I would also document this. I would contact families or CQC if no one listened to me.” Safeguarding incidents were discussed with staff in meetings for lessons learned and to prevent reoccurrences.

People and their relatives told us they felt safe. One person told us,” My [family members] can visit me knowing I'm safe here but I can't get out anymore because of my legs. Yes, I love it here, l try to engage with others which is one of the reasons l do the activities.” A relative said, “I have them both [family members] in here now as they could no longer cope at home. [Family member] had started to wander off in the night and we were worried they would have an accident, so we feel they are safer here as watched 24/7 now.”

Safeguarding systems were in place to safeguard people from abuse. The provider had safeguarding policies and procedures in place and had a procedure for ‘whistleblowing’. The registered manager and deputy manager were aware of the reporting procedures and raised appropriate safeguards when required. Staff had received training in abuse awareness.

People were involved in managing their own risks. For example, one person told us they had asked for a piece of monitoring equipment to be removed and this was supported by the service. A person told us, “I am not at risk, they are very careful of me as I was falling over at home, so careful as I get little turns and staff tell me to be careful, 6 months ago when I had one, I went straight away to the hospital.”

The provider had good processes in place to ensure people were involved in their care and support including risk. Care reviews recorded people’s views on the equipment required and the reason for this.

Staff had a good understanding of people's risks and how to safely support them. Any changes to people's care needs were identified quickly and referred appropriately. A staff member told us, “We might notice risks and tell management. We then monitor. We have a handover, and we can read the care plan. The unit manager updates us about anything new.”

Throughout the inspection we observed people being supported to move using mobility equipment, this was done safely, and staff told people what was happening and why.

The environment was purpose built and any maintenance issues were responded to effectively. On the day of inspection, a person had reported their room alarm was not working and this was replaced straight away.

Throughout the inspection, we observed staff were attentive to people’s needs and responded quickly to requests for support. The service ensured communal areas were not left unattended and people had staff on hand when needed.

The registered manager used a dependency tool to determine the levels of support people needed and help calculate the number of staff required to support people. The provider had recently increased staff across the service following a request from the registered manager. The provider had an effective recruitment and selection procedure in place. Staff had received training to enable them to have the skills and knowledge they needed to support people. Staff had regular supervision to discuss their training and support needs and regular staff meetings.

Staff we spoke with told us there were enough staff. A staff member told us, “I think there is enough staff. It is a nice place to work, teamwork is really good. The registered manager said, “I have got a very good staff team and they have worked hard these last 6 months; some are new to care, and I am so proud to see them develop, we have no wounds, and they tell you of any redness, the families are very happy, and I am empowering my staff.”

People and relatives told us there were enough staff. A person told us, “I have got to recognise faces, but they do change, particularly at weekends you see different faces, they are very quiet, always kind, and never rush you.” A relative said, “There seems to be enough of them [staff], and the personal care here is pretty good.”

Throughout the inspection we observed the service to be clean and odour free. The equipment was found to be clean and in good working order. Staff were observed using personal protective equipment (PPE) when required.

People told us the service was cleaned regularly. One person told us, “My room is kept clean, they do the laundry – I cannot fault it (home)” I am very happy here and would recommend it, it is a nice clean place.” A relative said, “Got a good housekeeper now and she has made a lot of difference, everywhere has been deep cleaned.”

People were supported to receive their medicines safely. The service used an electronic system which alerted senior staff to any delays in the administration of people’s medicines. Medicine audits were carried out regularly. Protocols were in place for as required (PRN) medicines. We identified 1 medicine administered where there was minimal recording of why it was administered or the effectiveness of the medicine following the administration. The registered manager followed this up immediately following the inspection and shared the concern with the staff administering medicines for lessons to be learned.