CQC report explained · a residential care home
What the CQC found at Admiral House - London
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection prevention and control arrangements were effective. This included hygiene, protective equipment, testing, social distancing, visitor controls and the management of possible outbreaks.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Requires improvement
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- There was a clear management structure, regular quality checks and evidence that the provider met its reporting duties. Inspectors said this area had improved from Requires Improvement and that the home was now consistently managed and well-led.
What inspectors found, May 2021
Rated Good overall; inspectors found effective infection controls and better management, although Safe was not rated at this visit.
This was an unannounced targeted inspection on 29 April 2021. One inspector spoke with two people, the managers and a deputy manager. Records about management, safety, incidents, medicines and care were also checked. Four health and social care professionals gave feedback afterwards.
The home supported up to 12 men with mental health needs, with 10 people living there at the time. People spoken to said they were happy and felt safe. Inspectors were assured that cleaning, protective equipment, testing, visiting controls and infection procedures were being managed properly.
The overall rating improved from Requires Improvement at the previous inspection to Good. Well-led also improved from Requires Improvement to Good. Safe was inspected for infection prevention and control but was not rated at this visit. The other overall ratings came from the previous comprehensive inspection.
Clear management
The home had an established management structure and regular checks covering areas such as health and safety, infection control and medicines.
“Governance procedures in place included daily, weekly and monthly quality assurance checks to monitor the quality of service provided” from the report
People felt safe
The two people spoken to said they were happy, felt safe and believed staff and managers would listen to their concerns.
“They felt able to report any concerns to the staff and managers and were confident they'd be listened to.” from the report
Good partnership working
Professionals gave very positive feedback about communication, support and outcomes for people using the home.
“There was evidence that the provider worked in partnership with various community professionals and external agencies, including Local Authorities and Mental Health Trusts.” from the report
Some people avoided meetings
minorPeople living in the home were reluctant to attend monthly meetings. Staff gathered their views individually instead, so ask how people can influence decisions and receive shared information.
“The people using the service at Admiral House – London were reluctant to attend the meetings held for them on a monthly basis.” from the report
- 01How do you make sure people who do not attend monthly meetings can share their views and receive important information?
- 02What infection control arrangements remain in place now that the COVID-19 restrictions at the time of the inspection have changed?
- 03How often are health and safety, infection control and medicines management checks completed, and can families see the actions from them?
- 04How do staff support people to attend health appointments and maintain their wellbeing?
- 05What evidence shows that the improvements since the previous Requires Improvement rating have been maintained?
This was a targeted inspection of infection prevention and control and Well-led; Safe was not rated, and the other overall ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 27 May 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2019
Rated Requires Improvement; inspectors found safe, kind care but weaknesses in personalised planning, follow-up and management.
This was an unannounced inspection on 20 May 2019. One inspector spoke with two people, the registered manager and two care workers. They reviewed care records, staff files, audits and other records, and received feedback from a healthcare professional.
The home was rated Good for Safe, Effective and Caring. People said they felt safe, liked living there and found staff helpful. Inspectors found safe medicine systems, enough staff, suitable recruitment checks, regular staff training and support for healthcare appointments.
The home was rated Requires Improvement for Responsive and Well-led. Care plans did not always show that people's goals had been followed up or changed when people were not engaging. Suggestions raised at residents' meetings were not always followed up, some areas needed refurbishment, and one incident had not been notified to the CQC.
The overall rating was Requires Improvement, down from Good at the previous inspection published on 16 March 2017. The report said the CQC would continue to monitor the home and plan further inspections.
People felt safe
People told inspectors they felt safe. Staff had safeguarding training and knew how to respond to possible harm.
“People using the service told us they felt safe.” from the report
Safe medicines
People said they received medicines on time. Records, storage and audits supported this.
“Medicine administration record (MAR) charts were completed correctly and in a timely manner.” from the report
Enough trained staff
The home had enough staff to meet people's needs. Staff received regular training and supervision relevant to mental health support.
“There were enough staff employed to meet people's needs.” from the report
Respectful care
Inspectors saw friendly interactions. People were supported to make choices, maintain their independence and come and go as they pleased.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Complaints were resolved
The home recorded two formal complaints and resolved both quickly to the complainants' satisfaction.
“There had been two formal complaints received, both of which were resolved quickly to the satisfaction of the complainant.” from the report
Goals were not always followed up
needs fixingSome care plan goals were not evidenced as completed or reviewed. Inspectors said targets should be made more realistic when people were not engaging.
“We found there were instances where people's identified goals were not always followed up.” from the report
Residents' suggestions were missed
needs fixingPoints raised in residents' meetings were not always discussed or acted on at later meetings.
“We saw that where people had raised points for follow up, these were not always explored or discussed at subsequent meetings.” from the report
Parts of the home needed repair
minorThe environment was dated, with a broken kitchen cupboard and damaged ceiling tiles. The cupboard was fixed the day after the inspection, but refurbishment was still being considered.
“The environment was dated and some areas were in need of refurbishment.” from the report
One incident was not reported
needs fixingThe manager told inspectors that one incident had not been notified to the CQC. The report says this was an oversight and would be submitted after the inspection.
“We did find that there was one incident that we had not been notified about.” from the report
- 01How are each person's goals now reviewed, changed and recorded when they are not engaging with the plan?
- 02What has been done to make sure suggestions from residents' meetings are followed up and reported back?
- 03Has the planned refurbishment of the kitchen and social areas been completed?
- 04What system is now used to make sure all incidents that must be reported to the CQC are notified on time?
- 05How do you make sure staff have consistent training, including the Care Certificate?
This was an unannounced comprehensive inspection covering all five CQC questions, including the premises and care provided; the previous overall rating was Good. This explanation was written from the published report of 27 June 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Admiral House - London
4 rated inspections over 6 years: the service has held its Good rating throughout.
- May 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2019Requires improvementdown from GoodWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 8 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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