Archived: Napier Lodge Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulations in relation to consent.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People’s records and pre-admission assessments did not provide a clear indication of their needs, lacked sufficient detail and guidance or were not always up to date to reflect changes in their care needs despite them being regularly reviewed by staff.

Following the inspection, we asked the provider to develop ‘Pen pictures’ for people which contained a summary of how people needed to be supported. This helped staff to meet people’s current needs.

The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Assessment tools were not used effectively to minimise risk to people. For example, RESTORE2 is a tool used to detect early signs of deterioration in people. The manager told us nurses used this, but records demonstrated this was not always used correctly. This increased the risk of significant harm to people through lack of appropriate, timely medical intervention.

We observed support at mealtimes needed to be improved. Staff did not always speak to people and support was functional rather than used as an opportunity for engagement with people to promote a good mealtime experience. This is important as it provides encouragement to people to eat as well as providing positive social opportunities.

Following the inspection, the regional manager sent us an action plan. This detailed ongoing plans to improve outcomes for people.

The service did not work well across teams and services to support people.

Staff did not work well with external professionals to ensure people were supported to access health services and have their health care needs met. We identified medicines were not available on a reoccurring basis. The manager told us the issue lay with a partner organisation but we noted the absence of an effective system at Napier Lodge for managing medicines to keep people safe. For example, there were no nominated staff to take responsibility for ordering, no daily stock check in place or information recorded when prescriptions were requested. The GP service nominated to Napier Lodge raised concerns about how, when and why referrals were made to them from staff at Napier Lodge. They also stated communication internally appeared poor as staff often called repeatedly about non-urgent concerns and did not escalate urgent matters. Following our inspection, a representative for the provider told us they did not agree with the views of the GP and had followed the direction from the GP service about when to escalate health concerns to them.

Following the inspection, the regional manager told us how they were working to improve communication in the service and with professionals external to the service.

The service did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. The service did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

Although people had been reviewed by specialist health teams, including mental health and diabetes specialists, staff at Napier Lodge failed to provide the necessary ongoing support to ensure people’s health and wellbeing. For example, people who required support to manage distress or regulate their emotions were not supported effectively. During our visit, we observed staff actions directly increased a person’s distress and frustration. Furthermore, staff did not keep effective monitoring records, which meant they were unable to identify triggers or implement appropriate strategies to prevent repeated incidents.

One person had a wound care plan. This evidenced a delay in involving external health professionals, poor monitoring from staff and did not include the outcome from another health professional’s visit. There were also delays in following updated guidance from health professionals. For example, a diabetes specialist changed 1 person’s medication, but this was not updated in the service for 5 days. This increased the risk of the person experiencing harm.

The service did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Care plans did not always include people’s goals, so the service did not monitor if goals were being achieved. This meant people were at risk of not receiving person centred care.

Care plans did not contain sufficient guidance to enable staff to undertake effective monitoring. For example, 1 stated, ‘Ensure I have eaten or drunk a sufficient amount’ and another stated the person should have ‘2 square meals’. However, there was nothing recorded to state what this meant in practice. We additionally identified weight monitoring for people at risk of malnutrition was not always in line with their care plan guidance.

The provider failed to ensure outcomes for people were positive and consistent and that standards of care were good. Staff did not receive the necessary support, training and supervision to provide positive and consistent care.

The service did not tell people about their rights around consent or respect these when delivering care and treatment. For example, 1 person who the service deemed as having capacity to make decisions about their care told staff they did not want to be regularly checked on. Despite this, staff checked on them every 15 minutes.

Decisions which involved restrictive measures, such as the use of movement sensors to monitor people had not prompted an assessment of people’s capacity, where appropriate. Also, there was no evidence of how a decision had been made, or whether the decision was in the person’s best interest.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the 2005 Mental Capacity Act. In care homes this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

DoLS had been requested for most people at the home whether they were able to go out unsupervised or not. One person who did not have a DoLS was not free to come and go as they wished. They told us they had to wait for staff to let out of the unit and out of the home. This compromised their freedom.

There were conflicting records about people’s capacity. For example, some capacity assessments stated people had capacity to make a particular decision, but DoLS records stated they did not. This meant there was not clear guidance for staff about what decision people could make.