CQC report explained · a residential care home
What the CQC found at Admirals Rest
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found environmental risks, including high water temperatures, uncovered radiators, mould and gaps in safety checks. Staff recruitment procedures were also not being followed, although medicines were generally managed safely.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- The home's audits and maintenance records did not identify or deal with important safety and recruitment problems. Inspectors found that management oversight was not robust enough.
What inspectors found, March 2023
Admirals Rest is rated Requires Improvement because inspectors found risks in the building, staff recruitment and management checks.
This was an unannounced inspection on 13 and 18 October 2022. Inspectors spoke with people, relatives and staff, observed care, checked care and medicine records, reviewed five staff files and examined safety and management records.
People and relatives said they felt safe and were satisfied with the care. Medicines were generally given safely, staff understood safeguarding duties, and people were supported to make choices.
However, inspectors found high water temperatures, uncovered radiators, mould, maintenance problems and missing checks on some environmental risks. Recruitment records were incomplete, and the home's quality checks had not found or dealt with these problems. The overall rating changed from Good at the previous inspection to Requires Improvement.
People felt safe
People and relatives told inspectors they felt safe with the care and support provided.
“People and their relatives told us people felt safe with the care and support they or their relative received.” from the report
Medicines
People received their medicines as prescribed. Records had no gaps, medicines were stored securely and staff had received training.
“People received their medicines safely and as prescribed.” from the report
Personalised support
Care plans and risk assessments gave staff clear, personalised guidance about people's needs and support.
“Positive behaviour support plans and risk assessments were personalised with clear guidance for staff to follow.” from the report
Good relationships
Inspectors found a friendly atmosphere, and staff knew the people they supported well.
“There was a relaxed and friendly atmosphere within the service. Staff knew people well.” from the report
Environmental safety
seriousWater temperatures were high enough to create a scalding risk. Uncovered radiators, mould, a stained mattress and missing legionella records also needed attention.
“We found high water temperatures in people's bedrooms and a bathroom placed people at risk of scalding.” from the report
Staff recruitment checks
seriousMost of the staff files checked did not contain proof of identity or interview records. This meant the provider could not show that staff had been properly assessed as safe to work with vulnerable adults.
“4 out of 5 staff files we reviewed did not contain proof of identity or interview records.” from the report
Weak management checks
seriousAudits and the maintenance log did not identify or track all the problems inspectors found. This meant there was not enough oversight of safety and quality.
“However, we found these systems and processes were not effective at identifying and addressing the issues we found during the inspection.” from the report
As-needed medicines guidance
minorInstructions for some medicines to be given when needed were not detailed enough. A handwritten medicines entry also lacked a second staff signature.
“Guidance in place for medicines prescribed 'as needed' (PRN) was not always sufficiently detailed for staff to know how and when to administer each medicine.” from the report
- 01Have all high water temperatures, uncovered radiators, mould and other environmental risks now been fixed, and how are they checked?
- 02Have every staff member's identity, employment history, interview records and other recruitment checks been completed?
- 03What monthly maintenance and safety audits are now in place, and can we see evidence that issues are followed through?
- 04How are instructions for as-needed medicines checked to make sure staff know when and how to give them?
- 05What progress has been made against the action plan requested by CQC?
This was a focused inspection of Safe and Well-led, following concerns about safeguarding; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 3 March 2023 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, January 2019
Admirals Rest was rated Good; inspectors found kind, safe and personalised care, with some gaps in staff training and quality checks.
The inspection was unannounced and took place on 27 November 2018. The inspector spoke with people living at the home, staff, the manager, relatives and health professionals. They reviewed care records, medicines records, staff files, training records and other documents.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People and relatives spoke positively about the care. Inspectors found respectful staff, personalised support, safe medicines management, suitable staffing levels and systems to protect people from harm.
The home had improved since the previous inspection in October 2017. Earlier problems involved safeguarding, consent, staff checks and training, and audits. Inspectors found these necessary improvements had been made, although some training records, staff induction and quality audits still needed attention.
Improved safeguarding
The home had corrected earlier problems with reporting and investigating safeguarding concerns. Inspectors found that alerts and required notifications were now being made.
“Records showed that safeguarding alerts had been raised when needed.” from the report
Respect and dignity
Staff supported people in a respectful way and asked permission before entering rooms or providing support.
“During our inspection staff always knocked on people's doors and asked for people's consent when supporting them.” from the report
Personalised support
Care plans described people's routines, preferences and support needs. They were reviewed with people and updated when needs changed.
“Care plans were regularly reviewed with people, and changes to needs were updated as and when necessary.” from the report
Safe medicines management
Medicines were stored, administered and recorded safely. The report found no medicines errors since the previous inspection.
“Medicines administration records (MARs) were accurate and clear.” from the report
Training gaps
needs fixingSome staff needed refresher training, and some newer staff had not yet completed medicines competency checks. The provider was aware and planned to review this.
“Most staff had up to date training, although some people needed refresher training for some subjects.” from the report
Mixed induction experience
needs fixingNew staff had an induction programme, but staff gave different views about how helpful it was. This matters because newer staff may need clear guidance about people's needs.
“One told us that they found the induction helpful, but the other stated that it was, "Woefully poor.” from the report
Brief quality audits
needs fixingThe home's audits were current, but some did not record enough detail about actions. This could make it harder to show that improvements were being made.
“These audits were all up to date, but some were brief.” from the report
Care information could be fuller
minorSome personal history and end of life information was limited. The manager said they would review this, although no one using the home at the time had specific end of life needs.
“We suggested that these could be more detailed, particularly for new staff joining the service.” from the report
- 01How do you make sure all staff, especially new staff, have completed medicines training and competency checks before giving medicines?
- 02What refresher training is currently outstanding, and when will it be completed?
- 03How do you check that new staff receive a useful induction and understand each person's needs?
- 04What actions have been recorded from recent audits, and how do you check that those actions are completed?
- 05How will you record my relative's personal history, preferences and end of life wishes?
This was an unannounced inspection covering all five areas of the home, including care, premises, records, medicines, staffing and management; the previous inspection was on 7 October 2017. This explanation was written from the published report of 17 January 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 Admirals Rest
3 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2018Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016
Registered with the Care Quality Commission on 21 July 2016.
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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