Archived: Napier Lodge Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.
This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to the management of risk and medicines, safeguarding people from abuse and staffing.

This service scored 31 (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 have a proactive and positive culture of safety. They did not sufficiently investigate safety events. Lessons were not learnt to continually identify and embed good practice.

People were not sufficiently involved in or consulted about reviews of concerns, accidents and incidents; or in planning to prevent similar incidents in the future.

The provider did not have an effective system to monitor accidents and incidents, or to identify any patterns or trends for individuals or across the service. There was a lack of effective investigation when things went wrong. We also noted an absence of analysis of why incidents may have occurred and of measures implemented to reduce the likelihood of reoccurrence. For example, records highlighted that 1 person had fallen on 5 separate occasions in a 3-month period and that another person had 3 choking episodes on 3 consecutive days. However, we saw little evidence of analysis of these incidents. Accident forms were not fully completed and lessons learnt were either not in place or insufficient. There was limited monitoring of safety and unacceptable levels of serious incidents or significant events, such that we were not assured that safety was a sufficient priority. Lessons were not learnt to improve practice and which placed people at significant risk of harm.

During our inspection, we asked for investigations into safety events that happened at the time of our inspection be carried out and we noted that these were completed more thoroughly. However, it was too early to tell if this improvement had been embedded and enabled care to be improved.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety.

Pre-admission assessments were completed prior to people moving into the service, however, these contained limited information to enable effective support to be provided. The provider told us after the inspection of their plans to improve the pre- assessment template by incorporating a form from the local GP surgery.

People’s care and support was not planned and organised with them. In addition, partner agencies expressed concerns about how the service worked with them to ensure people’s safety. We saw records from the service’s GP which asked the service to follow safer processes when making referrals, but we noted this guidance was not always followed. This increased the risk of the GP not seeing referrals and therefore being unable to respond safely to people’s health needs. Following the inspection, a representative of the provider told us this was not correct, and they had followed the advice from the surgery.

Records demonstrated there was often a delay of referrals being made but it was not clear why this was the case. For example, in 1 person’s care plan, it stated, ‘Staff to refer me to TVN [Tissue viability nurse]’. However, it was not until 5 months later that this was completed. We did not see evidence of learning from this incident so as to minimise chance of reoccurrence.

When health professionals had made changes to the support people required with their health conditions, these were not always followed in a timely manner. For example, a health professional changed the prescription of a person’s medication, but this was not changed in the service until 5 days later. Another person had their medication stopped for a health condition, but this was not reflected in their care plan. This put people at the risk of harm.

Following our inspection, the regional manager and manager told us how they were improving their working relationships with partner agencies to improve outcomes for people.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Prior to our inspection we received information from partner agencies about incidents that put people at risk of harm and abuse. For example, the poor management of falls and choking. Concerns were also raised about medicines management and supporting people at the end of their life and with ongoing health conditions. Additionally, there had been allegations of abuse both between people and from staff to people. These safeguarding concerns were being investigated by partner agencies at the time of our inspection. Although the provider was attempting to make improvements to ensure people’s safety, incidents of concern had continued, which led external professionals to move some people to other homes for their safety. During our inspection, we identified continued concerns about how the provider failed to protect people from the risk of abuse and harm.

Following our inspection, the regional manager sent us an action plan. This detailed ongoing plans to ensure people were protected against harm and abuse.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people's safety were not always assessed to ensure they were safe from avoidable harm. For example, some people took medication which increased the risk of bleeding whilst others were prescribed creams which were flammable. Also, some people did not use lap belts when using a wheelchair which increased the risk of them falling out. Risk assessments were not in place which increased their risk of harm.

Where risk assessments were in place, they lacked detail to ensure staff knew how to safely support people. For example, 1 person’s wound care plan did not include the wound size, details of the wound cleanser, dressing and frequency of dressing changes. This increased the risk of the wound not healing. The manager and some staff described 1 person as being the most complex person to support due to behavioural symptoms associated with their mental health condition. There was insufficient information in this person’s risk assessment about how staff should support them, and we observed staff acting in a way that increased their frustration. The lack of guidance in their risk assessment increased the risk of emotional distress.

Other risk assessments and care plans contained conflicting information. For example, 1 section of a person’s care plan stated they could not communicate pain but, in another section, stated they could. This meant it would be unclear how staff should assess the person’s pain.

We were not assured care records were always accurate or whether staff understood the information in them because staff sometimes told us different information. For example, 1 person’s care plan stated they should have an increase from 3 scoops to 6 scoops of thickener in their drinks to reduce the risk of choking. However, 2 staff members told us the person had 2 scoops of thickener. This lack of an accurate care record increased the risk of the person choking.

There was a lack of evidence people had been consulted about how they wanted their risks managed. This meant people’s risks were not always managed in a suitable way for them. For example, staff changed a person’s bedroom to try and reduce the risk of them falling and for another person, carried out frequent checks despite this being against their wishes. This increased confusion and agitation for these 2 people.

The local authority care homes team were supporting the home to provide safer care and improve their management of risk.

The service did not always detect and control potential risks in the care environment.

Staff completed various health and safety audits. However, we identified some shortfalls. When issues with the environment or equipment had been identified, records did not always demonstrate actions to ensure safety had been taken. For example, with the delays in motions sensors recorded in the maintenance log. This limited oversight and increased the risk of appropriate action not being taken.

The Personal Evacuation Emergency Plan (PEEP) file was not up to date. PEEPs are a tailored escape plans for individuals who may need assistance evacuating a building during an emergency, such as a fire. This failure to keep the file up to date increased the risk of people not being safely evacuated in the event of an emergency. Checks to reduce the risk of a bacterium called legionella that can proliferate in building water systems were not always in line with guidance from the Health and Safety Executive (HSE). This increased the risk of Legionella being present in the water system. The provider made improvements at the time of the inspection.

Other environmental safety checks were completed. External contractors had additionally checked and serviced aspects of the environment and equipment such as firefighting and moving and handling equipment.

The providers website stated the home was divided into 2 units, depending on people’s age and health condition. However, this was not the case at the time of the inspection and there was no evidence the compatibility of people living together had been considered. This increased the risk of people experiencing emotional distress.

Some consideration had been given to support people to orientate themselves around the home and find their rooms. Signs to help direct people and memory boxes which contained information about people were by their rooms.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The providers website stated they were a specialist service, supporting people with complex mental health needs. However, only 1 mental health nurse was employed, and other staff had received only limited mental health training. Observations and records showed people did not consistently receive appropriate support to meet their mental health needs. More can be read about this in the ‘Involving people to manage risk’ section of the report.

The provider had not ensured staff were competent in their roles. Prior to our inspection we received concerns from partner agencies about the lack of clinical skills of nurses and lack of communication skills of care staff. These concerns were shared with the provider who told us they had improved training and discussed concerns at meetings and handovers with staff. However, there were no competency assessments to assess nurses’ clinical skills or staff members communication skills which meant the provider could not assure themselves people would be safely and effectively supported. We identified concerns in these areas during our inspection. For example, 1 person had not been effectively supported when they had an incident related to their health condition. We also observed care staff who did not engage with people effectively. For example, a staff member did not communicate with a person when they were supporting them with their meal. The provider told us they had medication and safeguarding competency assessments that staff had completed, but we also identified concerns in these areas as outlined in the ‘Medicines Optimisation’ and ‘Safeguarding’ sections of the report.

To address staffing issues, the provider had moved some staff from other services in their organisation to Napier Lodge. This included a manager and unit leads. However, at the time of the inspection, it was too early to determine if this would ensure the necessary improvements in the service.

Staff were safely recruited.

The service did not always assess or manage the risk of infection.

The communal areas were clean overall; however, there was a lack of documented cleaning schedules to evidence regular cleaning of people’s bedrooms, deep cleaning or the cleaning of high-touch areas for example. This limited oversight and increased the risk of infection, due to the potential of inconsistent cleaning practices.

A leader told us, “I would say the building is clean, but it’s the little things which need doing which is why we’ve been given the go-ahead to get extra [cleaning staff]. She [the cleaner] was previously responsible for only 1 floor, and now she covers another floor as well." The operations manager told us; the staff were good at “chipping in” with the cleaning. This was not observed during our site visits.

There were effective processes in the laundry to minimise the risk of infection spreading. For example, people’s clothes were washed separately, and staff knew which laundry items required extra controls. The kitchen was clean and tidy.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The providers medication policy was not in line with best practice guidance from the National Institute for Clinical Excellence (NICE) to ensure the safe management of medicines.

Medicine records were not always clear, accurate, or detailed enough to support the safe and effective administration of medicines. For example, specialist instructions on how medicines should be taken were not in place. Protocols for ‘when required’ (PRN) medicines did not explain how staff should identify when a person might need the medicine. Records for creams and transdermal patches lacked information about where they should be applied or where they had been applied. Additionally, changes to medicine dosages made by specialists were not always promptly recorded or implemented. Where changes had been made to administration records, there was no process for these to be checked by another trained member of staff. The issues with medicines records increased the risk of a medicine error and harm to people.

Some people were prescribed PRN medicines to alleviate distressed emotions and behaviours associated with this. They can have a sedative effect. It was not clear these were administered appropriately, based on a review of the behaviours documented in 1 person's care and monitoring records. This increased clinical and safety risks for the person.

Stock ordering processes were not effective. There was evidence of medicines not being available when people needed them on a reoccurring basis.

Medicines audits were carried out, but these were not effective in identifying the issues found at the time of the inspection as described above.

Following the inspection, the regional manager sent us an action plan. This detailed ongoing plans to improve medicines management.