We carried out a review of the data available to us about Hallmark Admiral Court Luxury Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Hallmark Admiral Court Luxury Care Home, you can give feedback on this service.
We found the following examples of good practice.
• Arrangements were in place for family and friends to access the service safely for visits. These included temperature checks and personal protective equipment (PPE). There was a designated visitors room and the provider was facilitating visits in the gardens and peoples rooms.
• The service was very clean. There were cleaning schedules in place showing when cleaning had taken place including high touch areas and deep cleaning.
• People were admitted to the service safely following current government guidelines.
• People and staff were supported to follow social distancing guidelines. There were a variety of spaces people could access safely throughout the service for meals and social activities.
• Staff had access to the correct PPE at the service and were following government guidelines.
• Staff, people using the service and visitors had access to COVID-19 testing which was being carried out as per government guidance.
• Staff and people using the service had risk assessments in place to ensure risks in relation to COVID-19 were identified and managed safely.
We were assured that this service met good infection prevention and control guidelines as a designated care setting.
Admiral Court is a nursing home providing personal and nursing care to up to 60 people aged 65 and over who may or may not be living with dementia. At the time of inspection 60 people were living at the service across two floors, each of which has separate adapted facilities. One of the wings specialises in providing care to people living with dementia and residential care needs. The other for people who require nursing support.
People’s experience of using this service and what we found
People received outstandingly person centred and individualised care from a motivated, informed and exceptionally well led staff team.
The provider had strong visions and values focused on maximising people’s quality of life and cultivated a caring and supportive culture. Staff had embraced these values which were evident in all interactions.
Without exception people and relatives spoke in high praise of the registered manager, provider, extended management team, and nursing and care staff. One person summed this up, “Nothing is too much trouble, they always make themselves available to do things, the extra little things that really matter.”
Staff at all levels were described as exceptionally kind and caring and the provider encouraged staff and people to be kind in everything they did. Everything about an individual person’s life was celebrated. This had resulted in a kind culture at the home.
There were a number of unique staffing roles across the service led by a passionate and motivated registered manager, deputy manager, heads of department, lifestyles lead and dementia coordinator. These key members of staff supported nursing and care staff to provide an outstanding level of care to people through constant consultation and learning.
Staff understood the needs of each individual person and often went the extra mile to ensure people lived their best lives. There were numerous examples of people’s everyday lives being enhanced by creative, compassionate care with an extremely varied lifestyles programme.
The provider had heavily invested in staff training and development in best practice innovations which had resulted in significantly improved outcomes for people, particularly those living with dementia. They were constantly adapting the service to meet the needs of people well.
People felt valued and respected within the local community and staff encouraged people to maintain their independence and life skills, contributing to the wellbeing of others.
The service had exceptionally robust systems in place and oversight for monitoring the quality of care provided. Heads of department were continuously learning, developing and shaping the service, involving people living at the home. Therefore, people were confident they received safe care and treatment.
People had excellent access to a balanced and varied diet. Those with specific health needs were supported by knowledgeable staff and external health professional advice.
Medicines were managed safely and in line with best practice guidance. Every area of the physical environment offered varied, safe and in the moment meaningful engagement opportunities for people.
People were supported to have maximum choice and control of their lives and staff supported support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Rating at last inspection and update: The last rating for this service was good (published 24 October 2018)
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The service did not have a registered manager in place at the time of our inspection. The regional management team informed that recruitment to the post was currently underway. The provider advised that they were not going to rush this process, as they wanted to get the right person for the service. In the interim the service had a project manager who was very experienced in working within the sector and they would be working at Admiral Court until a new manager was appointed and settled into the service.
The project manager informed they had been in the home for a few months and since coming in they had reviewed processes that had been in place and looked at improvements that could be made without making too many changes that could be disruptive to the day to day running of the service. For example, previous manager had made changes to how the home was staffed and staff’s days off and annual leave request was being managed. This meant several of the staff were working three of four long days before having a day off. The project manager reviewed this process as to ensure all staff were getting time off work and the home was staffed at all times of the day and week.
There were a number of effective monitoring systems in place. Regular audits had taken place such as for health and safety, medication, falls, infection control and call bells. The project manager carried out a monthly manager’s audit where they checked care plans, activities, management and administration of the service. Actions arising from the audit were detailed in the report and included expected dates of completion and these were then checked at the next monthly audit. Records we held about the service confirmed that notifications had been sent to CQC as required by regulation
People benefited from a staff team that felt supported by the management team. Staff had handover meetings each shift and there was a communication book in use which staff used to communicate important information to others. It enabled staff who had been off duty to quickly access the information they needed to provide people with safe care and support. This showed that there was good teamwork within the service and that staff were kept up-to-date with information about changes to people’s needs to keep them safe and deliver good care.
The project manager told us that their aim was to support both the people and their family to ensure they felt at home and happy living at the service. The project manager added that they held meetings with relatives and people using the service as this gave the service an opportunity to identify areas of improvement and also give relatives an opportunity to feedback to staff; be it good or bad. People and their relatives also told us that they were involved in the continual improvement of the service.
The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People’s needs were being met. Although our observations showed that staff deployment throughout this inspection was good, staffing levels at weekends were not always maintained to the level of week days which was also reported to us by staff and confirmed in rotas we reviewed.
Although staff knew how to recognise and respond to abuse correctly, not all people felt safe and we found that the arrangements to keep people safe were not robust. Individual risks had not always been assessed and identified. Arrangements were in place to ensure that staff had been recruited safely and received opportunities for training, however not all staff had received regular supervision.
Opportunities for people to engage in social activities were variable, particularly for people who were immobile and/or remained in bed so improvements were required and this was the case at our previous inspection. Some people and their relatives did not feel involved in the care they received however improvement had been made since our last inspection.
There was a system in place to deal with people’s comments and complaints however we found that the registered manager had not investigated, recorded and dealt with complaints in line with the provider’s policies and procedures. We also found the Registered Manager had limited insight on complaints that had been dealt with or resolved.
Whilst we were concerned that some staff did not always recognise poor practice, suitable arrangements were in place to respond appropriately where an allegation of abuse had been made.
Arrangements in place to keep the provider up to date with what was happening in the service were not always effective. As a result there was a lack of positive leadership and managerial oversight. The Registered Manager had failed to use the systems put in place to identify and monitor the safety and quality of the service as they had failed to recognise the shortfalls or when they did there was a lack of action to rectify them.
People had sufficient amounts to eat and drink to ensure that their dietary and nutritional needs were met. People and relatives told us that staff treated people with kindness and were caring. Staff knew the needs of the people they supported. We found that people were always treated with respect and dignity and people received good care.
The Registered Manager had knowledge of the recent changes to the law regarding Deprivation of Liberty Safeguards (DOLS) and was also aware of how and when to make a referral if required. People were safeguarded from harm. Staff had received training in Mental Capacity Act (MCA) 2005 and had knowledge of Deprivation of Liberty Safeguards (DoLS).
As part of our inspection we met with the provider’s representatives who told us how they planned to bring improvements to the service and in terms of people’s care delivery.
Admiral Court provides care and accommodation for up to 60 people split over two units Amazon and Swallow. The inspection took place on the 12 August 2015 and 13 August 2015. The home is registered to provide a service to older people, younger adults and people with sensory impairments, mental health conditions and dementia, at the time of our inspection there was 60 people living in the service
The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Concerns we found during our inspection was confined to people who received care living on the Amazon unit of the service.
People’s needs were being met, however people’s comments varied on whether the service had sufficient numbers of staff to cover both units at all times of the day and night. There were concerns about the deployment of staff specifically on the Amazon unit in terms of supporting people with higher care needs.
Arrangements were in place to ensure that staff had been recruited safely and received opportunities for training, however not all staff had received regular supervision.
Opportunities for people to engage in social activities were variable, particularly for people who were immobile and/or remained in bed so improvements were required. People and their relatives did not feel involved in the care they received.
Some people had sufficient amounts to eat and drink to ensure that their dietary and nutrition needs were being met; however the dining experience for people was not always good on the Amazon Unit.
Not all the people in the service were always engaged in meaningful activities particular those cared for in their bedrooms.
Relatives and people who used the service knew how to make a complaint and were assured that all complaints would be dealt with and resolved in a timely manner. The service had a number of ways of gathering people’s views about the quality of the service which included holding meetings with people, staff and relatives. However, some people felt this was not effective in changing areas of the service and improving their care.
The service had a number of quality monitoring processes in place to ensure the service maintained its standards; however they did not always work to improve the service and recognise concerns that had been raised by the Local Authority.
Staff knew the needs of the people they supported. We found that people were always treated with respect and dignity and people received good care.
The manager had a very good knowledge of the recent changes to the law regarding Deprivation of Liberty Safeguards (DOLS) and was also aware of how and when to make a referral if required. People were safeguarded from harm. Staff had received training in Mental Capacity Act (MCA) 2005 and had knowledge of Deprivation of Liberty Safeguards (DoLS).
We thought about what we found and asked the questions that we always ask; Is the service safe, effective, caring, responsive and well-led?
This is a summary of what we found:
Is the service safe?
When we arrived at the service we were asked to sign the visitor's book and our identity was checked. This meant that people were protected from unwanted visitors such as others who posed a risk to their safety.
The manager had carried out regular safety checks to ensure that systems, practices and the building itself were safe for people who used the service. People told us that they felt safe living in Admiral Court. One person said, 'I feel safe and secure living here. They look after me well and are there when I need them.' Another person said, 'When I press my buzzer someone always comes very quickly.'
Staff had received training in safeguarding vulnerable adults from abuse (SOVA), the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). This meant that staff had been given the information that they needed to help ensure that people were cared for safely. Health and safety checks had been carried out and issues had been dealt with appropriately. This showed that the service had systems in place to help keep people safe.
Is the service effective?
People who used the service told us that they felt that it met their needs. One person said, 'I never have to wait too long for help when I need it as the staff are there quickly.' Another person said, 'They make sure I get what I need, when I need it, they are so kind and helpful.'
People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure their safety and welfare. The care records were generally well written and had been reviewed and updated monthly. However, the care planning system was bulky and care files contained both old and new information. This meant that it was sometimes difficult to know what information was current. The service was in the process of implementing a new care planning system which, when completed, should ensure that all of the information recorded was current. This meant that generally the service was effective and staff knew how to meet people's needs.
Is the service caring?
We saw staff interacting with people throughout our visit on 19 June 2014 and their interaction was good. Staff treated people respectfully, with dignity and patience. People told us that all of the staff were kind and caring. One person said, 'It is wonderful here, people are all so kind and helpful to me. Nobody is ever unkind to me, quite the opposite. I have no complaints and feel that I am very lucky to live here.' Staff displayed compassion and understanding when interacting with people.
People told us that the staff treated them respectfully at all times. People's preferences and diverse needs had been recorded in their care files and care and support had been provided in accordance with their wishes. This showed that people were cared for by kind and caring staff.
Is the service responsive?
People told us that they had plenty to do. One person said, 'I like reading newspapers and watching television. We have a cinema upstairs and I often watch old movies that interest me.' People told us that the staff supported them to get up or go to bed when they wished. They told us that staff supported them to visit local parks and for walks in the local community.
People were supported to see other professionals such as a general practitioner, chiropodist, optician, and district nurse. This showed that people's general health care needs were met and that the service was responsive to people's changing needs.
Is the service well-led?
There was a good quality assurance system in place. All of the people we spoke with who used the service told us that they were happy with the quality of their care. They told us they were happy with the staff, the food, their healthcare, the laundry and their environment. All but one of the visiting relatives who we spoke with also told us that they were happy with the quality of care provided at Admiral Court.
People told us that their opinions and preferences were always listened to and taken into account. The building had been designed with various areas where people could spend their time, taking part in many activities. We saw that the service had its own cinema and pub for people to use when they wished. One person told us, 'This is my home, not a home that I live in, it's wonderful here. I am very lucky to live here.'
The registered manager had carried out regular audits of the service's systems and practices. People who used the service and their relatives had participated in regular meetings where they were able to discuss any issues. The manager told us that a steering group had been set up to look at ways to improve both activities and the dining experience for people living with dementia. One relative spoken with told us that they were involved in this steering group. They had put forward some suggestions and the service had put them into practice.
People told us that they knew how to complain. They said that they had no need to complain because any issues raised had been dealt with immediately. Staff told us that they were confident in the management of the service. People told us that they saw the management team on a daily basis. This showed that there was an effective quality assurance system in place and that the service was well-led.
There was a good range of activities on offer which included walks around the local community such as to local parks and shops. People told us that there was always 'plenty to do' and that they 'enjoyed the films in the cinema room'.
There were good procedures in place for handling medication. Staff had been trained in handling medicines and their competence had been regularly assessed.
Recruitment practices were good. Staff received a good induction and they told us that they shadowed more experienced staff until they felt confident in working alone. Staff are well trained and supported to do their work.
There was a good complaints procedure and people told us that staff were responsive to their concerns. One person said, 'If anything is not quite right I tell the staff and they make sure it is dealt with quickly.'
There were procedures in place for safeguarding adults and staff showed a good awareness of them and more than 70% of staff had received training. Although staff told us that they felt supported; the records showed that no supervision had taken place. The feedback we received from relatives was positive about the quality of care at Admiral Court. One relative said, 'The home is lovely and the care staff treat my family member with dignity and respect.' There was a clear quality monitoring system in place which had identified the need for improvements. A new manager is due to start work at the end of October 2012.