Admiralty Care Home

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. This is the first assessment for this newly registered service. This key question has been rated good. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

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.

The provider supported people to be the lead in their care, promoting dignity, respect, and valuing people as individuals.

Staff had a clear understanding of these values. One staff member told us, “We are all here for the residents; they put a smile on our faces, and we try to put a smile on theirs.” Another staff member told us, “They are part of our family.”

The manager told us that being visible was important to enable them to oversee the culture of the service and provide support to staff.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was visible and clear leadership in the service. Staff knew who to go to if they needed support to meet people’s needs and told us the manager was approachable and supportive. One person told us, “The manager is very nice. She often pops in and asks if there is anything you want.” One staff member told us, “I can go to her office anytime, her door is always open, and I know she would listen and support me.”

The manager told us they felt supported by the provider and encouraged her staff team to discuss with her any challenges they may face. She told us that work-place adjustments were made to staff schedules to ensure that staff felt supported and valued when the need arose. For example, one member of staff has been supported to return to work after a year by facilitating different arrangements.

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

Staff told us they felt confident to voice their concerns about anything in the service to the management team, and to approach external authorities if needed. One staff member said, “The residents are my priority. If something is not being dealt with, I would certainly take it further.”

The provider had processes in place which supported staff to speak up about any concerns within the organisation. The manager told us they operated an open-door policy, and welcomed residents, staff and visitors to raise concerns with the management team. The manager told us, “I make sure I am open, transparent, and always have my door open. Their confidentiality was protected, and I am happy to receive any issue, whether verbally or in writing. I check in with staff daily and encourage the residents to raise any worries with me when I walk around the home which is several times a day."

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.

Staff told us they were treated well and supported equally by the management team. The provider had processes in place to encourage an inclusive culture and optimise staff well-being. Any issues were discussed at team meetings, in handover or during supervision. Staff told us they would not hesitate to speak to the management team if they needed to. Staff surveys had taken place to gain their views about how the service could improve, and there were programmes in place to support staff to develop in their role. One staff member told us, “The teamwork is very good.”

The manager told us they made adjustments to accommodate staff’s personal circumstances, and focussed on providing an environment whereby work-place issues could be discussed on both a formal and informal basis. The manager told us, “Agincare has a dedicated Welfare Officer who is responsible for all aspects of the pastoral care of our new international team members. This supports the well-being and cultural experiences of our workforce."

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were systems in place to support the manager to identify and address risks to the service and quality concerns. The manager reviewed audits, and quality checks were completed which included health and safety, medicine’s management, staff training and falls monitoring. Outcomes from these audits were discussed with the management team and action plans put in place to address the areas required. For example, the manager has implemented new safety protocols to prevent falls and injuries, significantly reducing the number of incidents in the home. The manager has also improved communication strategies with relatives and observed an increase in family engagements and satisfaction levels. One relative told us, “The manager has always been available whenever I wanted to speak with her, and she has always reported back to my mum, which I think shows deep respect and courtesy to mum.”

The quality of the service was discussed and shared with people, their relatives and staff. Their views on how to improve the service were sought and where possible, actioned.

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. The registered manager told us, “The senior staff liaise directly with the district nurse team, community continence team and the chiropodist. We work with the local authority and the DoLS team to ensure that residents are safe and protected from harm.” Visiting health care professionals recorded their visits onto people’s electronic care plans, ensuring that people’s records were accurate and secure. The local authority safeguarding team has played a significant role in the improvements implemented at the service, and the home continue to receive valued guidance and support from them as needed.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service ensured they continued to learn and improve the service. We noted they had implemented learning from safeguarding incidents and accidents and shared these with staff to drive improvement. The management team were keen to continue to build on positive relationships with partner agencies and the local authority. The manager told us, “Moving forward, we shall continue to prioritise staff training and development to uphold high standards of care. By cultivating a culture of continuous improvement and learning, I want to create a supportive environment where staff feel empowered to provide the best possible care for our residents."