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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to fit and proper staff, as safe recruitment practices had not been followed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements had been made following our previous inspection. The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We observed staff listening to people and responding to their concerns. Staff knew what incidents to report and how to report them.

The service investigated incidents thoroughly and shared outcomes with people and relevant stakeholders. We saw evidence of change as a result of incidents which had occurred.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure the provider could take appropriate action to mitigate these risks.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had a robust admissions policy in place. The registered manager was able to explain the process including assessing people’s needs to establish suitability, ensuring specialist equipment was available and staff had additional training if required.

The provider was working with another organisation to ensure there was a focus on planning for people living with Dementia to have a good day. This was to ensure people were consistently supported when they were distressed and to understand what had caused the distress so positive changes could be made. This also included adaptations to the environment to help minimise confusion for people.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally.

The service shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies. Where restrictive practices were in place, Deprivation of Liberty Safeguards (DoLS) were in place or had been applied for, to legally authorise restrictions placed on people to keep them safe.

The provider worked well with people to understand risks, however, documents did not always contain accurate information. Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

People were assessed for risks of falls, risk of choking and risks relating to medical conditions. We reviewed people’s care plans. Some care plans contained conflicting, or not enough information, for example, care plans relating to bowel management, epilepsy and fluid intake. However, we were assured staff we spoke with knew people well.

When risk had been identified staff used specialist equipment to monitor people’s health conditions.

The provider did not always detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We reviewed staff fire evacuation training records. These did not evidence all staff had been involved in a fire evacuation drill. They also did not evidence a nighttime simulated fire evacuation had taken place, as per the provider’s policy. During 1 evacuation practice, concerns were raised about some staff’s lack of knowledge and action. We could not see evidence this had been raised with the staff members. We spoke with the registered manager about this who told us during our inspection visit, they had prioritised fire evacuation practices with staff and would be completing these weekly to ensure they captured all staff.

Health and safety and fire safety risk assessments were completed and checks made of equipment to ensure it was safe to use. Regular audits were undertaken to ensure the environment and equipment remained safe to use. Any concerns were reported to the management team or appropriate person for further action.

The provider made sure there were enough qualified, skilled and experienced staff to meet people’s needs.

However, the provider did not follow safe recruitment practices. Pre-employment checks had not always been completed when recruiting staff. Staff recruitment records did not contain a full employment history. Where there was a partial recruitment history, gaps in employment had not all been explored to support the provider in determining whether staff were of good character. The provider’s recruitment policy did not detail the legal requirements in relation to required pre-employment checks. This increased the risk staff unsuited to care work, would be employed in the service. We also found this concern at our previous inspection.

The provider did not always make sure staff received effective support, supervision and development. We reviewed staff supervisions and found these were not completed quarterly in line with the provider’s policy. Staff supervision is important to make sure staff competence is maintained to carry out their role. We also found this concern at our previous inspection.

The registered manager had a training matrix in place. Most staff had completed all their statutory and mandatory training and competency assessments to ensure they were able to meet people's individual needs, although there were area’s which required improvement, for example, 13 staff had not attended safeguarding training. Where staff had not completed training, they were booked on to a session.

Staff and relatives told us there were mostly enough staff and rotas confirmed this.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had a robust up-to-date Infection Prevention and Control (IPC) policy and staff attended IPC training.

Relatives told us the home was clean. One relative told us, “Staff wear gloves when they clear dinner and give medication. They wash their hands. The home is clean, very impressive.”

We reviewed cleaning schedules which were consistently completed. We observed the home was clean.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Our observations and records we checked showed people overall were having their oral medicines administered as prescribed. However, as we had identified during our previous inspection in 2024, the staff did not always apply and record the application of emollient and barrier creams as prescribed. We found unopened creams dating back to almost a year without any explanation. The medicine administration records (MAR) were paper based. The MARs were not always accurate. We found several examples where medicines were recorded on the MAR; however, these were not in stock, and the staff informed us this was because these medicines had been discontinued.

Medicines, including controlled medicines, were stored securely. The staff now recorded opening dates for liquid medicines and eye drops. The staff monitored and recorded the room and fridge temperatures for the medicine storage areas. However, this was not always done daily, and we found gaps in the temperature monitoring records.

Some people were prescribed medicines to be administered on a when-required basis for health conditions such as constipation, pain, and anxiety. However, PRN protocols or information in care plans were not always person-centred for these medicines to be administered consistently. On 1 of the units, we reviewed paracetamol PRN protocols for 4 people. All 4 protocols were identical. Care plans were in place, but these were not always accurate in recording the current prescribed medicines.

Some people were administered medicines covertly. The staff had carried out an appropriate assessment and followed due process to administer these medicines safely.

There was a medicine policy in place. The staff had been trained and competency assessed to handle medicines safely. The current management has made some improvements by carrying out audits. However, these audits had not identified concerns that we found during the inspection.