Archived: Napier Lodge Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the service met people’s needs.

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulations as people were not supported in a person-centred way.

This service scored 32 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People did not experience person-centred care. Staff engagement was poor and focused on tasks rather than people as individuals.

Care plans were not sufficiently detailed, reflective of people’s current needs or personalised. This impacted the care people received. For example, 1 person did not like the taste of a blood sugar level raising medicine but nothing was recorded about how staff worked with the person to manage this or what alternatives could be used. This meant when the person’s blood sugars were reduced, staff did not have the information on how to effectively manage the situation. Care plans did not include people’s goals or longer-term aspirations. This meant staff did not have the information to support people towards meaningful outcomes and improve people’s quality of life.

People’s rooms were not always personalised. Although the compliance manager stated this was based on individual choice, there was no evidence these people had been actively supported to personalise their environment in line with their needs or preferences.

Care plans were being worked on at the time of the inspection, some improvements had been made and the regional clinical manager told us of their plans to continue this.

There were significant shortfalls in how the service understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

People’s care was not joined up or flexible because people were not involved in any care planning or decision-making.

People’s health conditions were noted within their care plans, however, sufficient information to guide staff on how to manage these was not always available. Where there were changes in people’s needs or advice from professionals this information was not always recorded in the person’s care records, so information could easily be missed. Therefore, we could not be assured the service ensured continuity of care regarding people's health care needs.

The people who lived at Napier Lodge had a mental health diagnosis which increased their vulnerability and risk of poor care. This had not been effectively considered, and subsequently we saw evidence of where people routinely received poor care. We were not assured that people’s care and treatment was delivered in a way that met their assessed needs in a joined-up, co-ordinated and responsive manner.

The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

It was not always clear how people were supported to make their needs known. Some people had communication difficulties, but their care plans provided limited information for staff. For example, in 1 person’s plan it was documented, ’Staff should learn and pay attention to non-verbal cues and gestures that I may use’ but there was no description of what these were or if staff had identified what they meant.

Some effort had been made to provide people with information about how to raise safeguarding concerns and complaints in an easy read format. Pictures were provided on the activities schedule with the aim of making this more accessible for people and although we did not observe picture menus being used, a representative of the provider told us they were in place.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

Although methods were in place to receive feedback from people such as a complaint’s procedure, surveys and meetings, it was not clear how this information was used to improve people’s experience of the service they received. For example, concerns had been raised about people being roughly handled by staff, about the fire procedure and the care provided. Actions to demonstrate improvements had been made but reviews of their effectiveness were not recorded. When we spoke to the regional manager about this, they acknowledged they had not “closed the loop” and told us they would look into improving this.

The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

People at Napier Lodge relied on staff to access healthcare treatment for them. However, this was not always done in a timely manner. For example, 1 health care professional noted earlier support could have prevented a person’s health from deteriorating and requiring hospital admission. Records also demonstrated a potential delay in treatment for a person’s wound care.

When people were newly admitted to Napier lodge, staff did not always register people with the GP who was linked with the service and carried out weekly ward rounds. This meant these people may not be able to easily access healthcare when they needed it.

Care plans did not always clearly demonstrate what access people had to support with their oral, foot and hearing healthcare needs. This put people at risk of not having their health needs met.

People’s ability to access facilities outside the care home was not clearly documented in their care plans. This meant staff did not have guidance on who could access external health appointments, who would need support and how this support should be provided.

The people who lived on the 1st floor of the home could not go downstairs, access the garden or leave the home without staff letting them. One person told us they had to frequently wait to be able to access these areas and found it frustrating.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

The provider had not always ensured they found out the views of people less able to speak about their needs and preferences. Engagement was minimal and there was little evidence people’s communication needs had been explored or met.

Care plans lacked guidance on how to support people’s unique needs to ensure positive outcomes. People or relatives had not been involved in care planning meaning people were not involved in making informed decisions. People received poor care, experiences and outcomes. The provider had not taken effective action to address this at the time of the inspection.

Staff had completed equality and diversity training but had not been able to effectively put this into practice due to the poor culture and lack of support and supervision from leaders.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

At the time of our inspection, the service was not supporting anyone with end-of-life care. A partner agency told us they had moved all people out of the service who had required end of life care because staff at Napier Lodge did not have the skills to safely and effectively support them.

Care plans did not include sufficient information on how people would like to be cared for when they came to the end of their life. People and their relatives were not consulted on their preferences and routines or were part of the care planning process.