Admirals Rest

Updated 3 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 3 inspectors and 1 Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience contacted people’s relatives by telephone to request their feedback. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Admirals Rest is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Admirals Rest is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service and 3 relatives. We spoke with 4 members of staff including the registered manager and support workers. We undertook observations of people receiving care to help us understand their experiences. We reviewed a range of records. This included 3 people's care records and 5 people's medicines records. We looked at 5 staff files in relation to recruitment. A variety of records relating to the management of the service and quality assurance were reviewed including accident and incident records and audits. We sought feedback from professionals who work with the service.

Updated 3 March 2023

About the service

Admirals Rest is a residential service providing personal care for up to 6 people with mental health support needs. The service consists of one adapted building, which includes individual bedrooms and communal spaces and an accessible garden. At the time of our inspection there were 5 people using the service.

People’s experience of using this service and what we found

People and their relatives told us people felt safe with the care and support they or their relative received. However, despite some positive feedback, we found concerns with environmental risks, staff recruitment and management oversight which placed people at increased risk of harm.

The provider had systems in place to monitor the quality and safety of the service, however they did not identify and address the issues we found during the inspection.

Safe staff recruitment procedures were not being followed.

Environmental risks were not always safely managed. Risk assessments in place identified and assessed risks associated with people's care and support with guidance for staff to follow.

People received their medicines safely and as prescribed. Staff had received safeguarding training and were able to demonstrate an understanding of their responsibility to report any concerns.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The registered manager sought the views of people using the service. Staff told us they were well supported. People and their relatives told us they were satisfied with the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 17 January 2019).

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted due to concerns received about safeguarding. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with environmental risks and premises, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Admirals Rest on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in regulations relating to environmental risks, staff recruitment and management oversight at this inspection. We made a recommendation about the maintenance of the premises.

Please see the action we have told the provider to take at the end of this report

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.