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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we did not assess enough quality statements to rate this key question. At this assessment this key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance. The providers governance system failed to identify all the concerns we found during this inspection.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

However, although they understood the challenges and the needs of people; the care people received did not always reflect the service’s values and objectives as set out in their statement of purpose. People did not receive care that was always high-quality residential care, for example, some care plans relating to bowel management, epilepsy and fluid intake contained conflicting, or not enough information.

The registered manager told us, “We have a corporate induction for all staff, so they understand what our values are and to ensure the values embedded.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and strived to embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

However, we identified breaches of the legal regulations and concerns in areas such as fit and proper staff and governance. We found some areas of concern from our last inspection had not been acted on effectively. Leaders had not always independently identified and acted on all these concerns prior to this inspection. Where the provider had identified concerns, they failed to drive improvement. This meant some development was needed in their skills and knowledge to lead effectively.

People and relatives spoke positively about the registered manager and told us they regularly checked in with them.

Most staff members told us, the registered manager was doing well and was visible, approachable, and making improvements.

The registered manager told us they received ongoing support and development in their role.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People living in the services were asked for their views and were given the opportunity to speak up daily both informally, in meetings, and through surveys. We reviewed people’s daily notes and meeting minutes and noted people spoke up, their decisions and choices were respected, and action was taken as a result. We reviewed people’s surveys where they were encouraged to speak up. This meant people’s voices were heard.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff felt supported to give feedback and were treated equally, free from bullying or harassment. They told us they had access to relevant policies.

The manager told us about the organisations flexible working policy which meant staff could apply for adjustments in their work to be made if needed. They gave examples of when this had happened in practice.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s own governance systems had failed to identify people were not always receiving effective care and prompt action had not been taken to make improvements.

Quality assurance audits had been completed, however, these had not always been effective in identifying the shortfalls we found at this inspection, such as conflicting or lack of information in care plans, medicine record shortfalls, not monitoring some people’s care to ensure they were repositioned in accordance with professional guidance, mental capacity assessments not being completed correctly or not always in place, staff not receiving regular supervision and the recruitment concerns. We also found these concerns at our previous inspection. Although there was some confidence in the registered manager, they required time to make changes and embed them into practice.

The registered manager was able to confidently tell us how they ensured safe record keeping by following the principles of General Data Protection Regulation (GDPR).

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Professionals, staff, and the registered manager shared with us positive examples of collaborative working in partnership. One professional told us, “They provide a safe, caring, homely environment. Whenever I visit there is a light mood and lots of smiles from both staff and residents. The staff are willing to accept support, follow care plans and be an advocate for the residents. There are often forms of entertainment going on and it is lovely to see the residents being encouraged to mix with others rather than in the isolation of their rooms, although this option is available to them should they want some private time.”

The provider strived to focus on continuous learning and improvement across the organisation and local system. However, we found some concerns during the inspection which we have highlighted throughout our report. Although the provider was motivated to learn and improve the service for people, they were limited by the lack of effective risk and quality monitoring systems. This meant they might not always be aware of shortfalls to enable prompt improvement and learning.

The provider was responsive during our inspection and told us they were taking learning from this inspection and would be sharing this across their organisation. They also shared with us an action plan during our inspection.

The provider was working with another organisation to ensure there was a focus on improving the lives of people living with dementia, to help reduce some of their anxieties. They had undertaken a lot of work to the environment, which gave people familiar areas to access, tactile objects to use and a feeling they were not living in a locked area.