The purpose for this unannounced inspection was to determine if the staffing levels at night time were sufficient to meet the needs of those who lived at the home. Concerns had been raised by a whistle blower about the number of staff on duty at night being inadequate. This inspection was conducted on 2nd March 2015 by two Adult Social Care Inspectors from the Care Quality Commission (CQC).
We arrived at Longton Nursing Home at 9pm, just as the day staff were going off duty and the night staff were arriving for work. A verbal handover took place, so that a summary of recent events could be passed to the oncoming shift.
We established that there were 57 people who lived at the home and a complement of five staff members on the night of our inspection. The staff team included two qualified nurses, although one was working as a care assistant during this particular shift. We were told everyone with the exception of three people required two staff members to assist them with personal hygiene and mobilisation during the night.
During the course of the inspection we gathered evidence against the outcomes we inspected, to help answer our five key questions;
Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?
Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with those who used the service as well as care staff and from looking at records. We visited the home at night time and therefore some people were already in bed. However, we were able to speak with four people, who were enjoying a hot drink and biscuits in the lounge.
If you want to see the evidence supporting our summary please read our full report.
Is the service safe?
People told us they were happy to be at the home and felt safe living there. One person said, "They (the staff) are kind and they are very thoughtful." Another commented, "They are always very, very busy."
All staff we spoke with told us that staffing numbers did not alter in accordance with the dependency levels of those who lived at the home.
The day following our inspection the manager provided us with a copy of the dependency scores for each person during January and February. She told us she reviewed these every month, in accordance with a dependency rating scale, a copy of which she also provided. However, there was no evidence to show how the numbers of staff were calculated from the results of the tools used. We spoke with the manager who said she worked the staffing levels out in accordance with how many people needed nursing care and how many were assessed as requiring residential care, but there was no structured format in place. She said there were 13 staff on duty during the morning, 10 in the afternoon and 5 at night.
Records showed that there usually five members of staff on night duty and this figure did not seem to vary from week to week. We spoke with the manager the day following our inspection who told us there were five staff members allocated on night duty and this was sufficient for the number and dependency levels of those who lived at the home. She told us people's needs had been fairly stable for some weeks.
We noted call bells were answered reasonably quickly and care files showed how often people wished to be checked during the night.
We were told not to use the small passenger lift, as it was 'unsafe'. We were told people who lived at the home did not use it. This maintenance issue needs to be addressed, so that the particular lift is safe for use and therefore people's safety is protected.
Is the service effective?
We arrived at the home at 9pm, just as staff were changing shift. We noted a verbal handover took place. This enabled the night staff to be fully aware of the current situation in relation to individual needs and to be updated with any changes that had taken place since they were last on duty.
Is the service caring?
We toured the premises and found the atmosphere to be calm and relaxed.
The temperature in the lounge was cool. One very frail person was sitting in a reclining chair. She was inappropriately dressed with bare arms. She told us she was cold. One staff member responded by saying to us, 'She is always cold'.
Staff made several remarks to us when referring to those who lived at the home, which were undignified and derogatory. For example one person was referred to as a 'feeder' and others collectively were referred to as 'feeders'. Another person was referred to as a 'wanderer' One member of staff said, "We put the little ones in bed first." This sort of language is unacceptable. It does not promote people's dignity or demonstrate a caring approach.
Is the service responsive?
When we arrived at the home we found some people had already retired to bed, but we were told this was their choice.
Written instructions for staff were on the notice board in the office, which identified people who were to be assisted out of bed, washed and dressed before the day staff arrived for duty at 8am. This list also identified which day of the week individuals were to be assisted with a shower or bed bath. This practice was not person centred or responsive to people's individual needs and wishes.
We looked at the care records of eight people who lived at the home. We found the time people liked to go to bed or when they preferred to get up in the morning was rarely documented. However, one plan of care was more person centred than others we saw, although the information provided about personal care preferences did not coincide with instructions given to staff.
We were told everyone was in bed by 11pm, except for one person, who alerted staff when she wished to be assisted to get into bed around 1am. This was recorded in her care file.
Most records we saw were very vague about certain areas of need. Specific details had not been recorded within the individual plans of care. This did not promote person centred care planning.
Is the service well led?
We were told the manager did not have the authority to organise agency staff, but she had to seek approval from the provider. This arrangement did not allow the manager full control of the staff rotas or autonomy to manage the service within her responsibilities. We were told the provider recently refused to allow the manager to request agency cover for staff sickness on night duty, which left the shift short staffed and this was confirmed by the staff rota we saw. However, the duty rotas did show agency staff were occasionally used at night time to cover staff shortages. No-one from the management team attended the home that night to assist with the additional workload.
We were told spot checks were never conducted at night to determine if night staff were performing well or if there were any specific issues relating to night work.
We were told that staff meetings were held, but that staff did not feel they would be listened to if they raised the issue of staffing levels at night.