Archived: Napier Lodge Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance of the service.

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 always have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider did not always provide clear direction to staff about the values and behaviours expected of them or the standard of care they were to provide. Leaders and staff were not able to tell us what the values of the organisation were. People had been receiving task-based care focused on their physical needs such as personal care rather than providing holistic care. However, the new leadership team were working to improve the culture of the service and told us they were now focussing on people as individuals. The changes needed time to embed into staff practice.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

Prior to our inspection, partner agencies had raised significant concerns about the leadership of the service. The provider had responded by both changing and increasing leaders in the home. Most of these leaders had been at Napier Lodge for a short time when we inspected. Although they demonstrated a desire to make the necessary improvements, there was still a lack of visible leadership and modelling of expected behaviours and values in the service. We were also concerned they did not fully understand the issues in the home or the impact they had on people. For example, 1 leader told us, “What I see when I’m up there [on a unit] is good care.”

The manager told us service risks were reviewed monthly at corporate level, but Napier Lodge was not initially on the risk register. It was later added as a moderate risk. This was not in line with our findings or those of partner agencies and meant we were also not assured senior leaders had understood the severity of the issues.

Despite this, staff were positive about the leadership team and told us they were well supported by them.

Staff had not always felt they could speak up and that their voice would be heard.

A new leader supporting the service told us staff had previously not been raising concerns about alleged abuse and poor practice but had just recently started coming forward to whistle blow. They went on to explain additional support and training had been provided for staff so they could address the culture and issues in the service. At the time of inspection, this was a work in progress.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Prior to our inspection, a partner agency told us of a ‘cultural divide’ amongst staff in the service which had caused issues. A leader confirmed this during our site visit and said they had come to learn of issues between staff of different cultures. They told us they had reviewed rotas; staff mix and begun additional work to address this.

Staff told us teamwork was improving.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems and processes were not operated effectively to ensure the service was safe and people were receiving high-quality care. This led to multiple breaches of regulations and placed people at risk of harm and abuse.

The concerns found at the inspection included but were not limited to, safeguarding people from abuse, risk and medicines management, the skills of staff, consent and supporting people in a dignified and person-centred way. We also identified a lack of adequate governance arrangements for monitoring incidents and identifying any trends for individuals or across the service. In addition, governance arrangements for supporting staff to work with key organisations and support joined-up care were ineffective.

The provider did not have systems of governance in place to ensure risks to people had been reduced. Where some risks had been identified by the inspection team or partner agencies, a lack of effective action was taken or appropriate governance arrangements were not in place. For example, where risks associated with people’s mental health had been identified, there was insufficient guidance to inform staff how to reduce these risks. This meant people were at continued risk of harm.

Records were not always detailed and up to date. For example, care plans were not detailed enough for people to receive person-centred care. Records relating to the management of the home were additionally not always in place or complete such as cleaning schedules and PEEPs.

The service did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Staff and leaders did not always work in partnership with health care professionals to support good health, care provision and outcomes for people. Provider records highlighted instances where staff did not always escalate concerns to health professionals when people experienced a deterioration in health or wellbeing.

There were limited opportunities for people to engage with the local community to meet their wishes, preferences and choices.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider lacked an effective process for improving the quality of care for people. Although the provider had an action plan in place, this did not identify all the concerns we found during this inspection and did not drive the necessary improvement.

As detailed in the Safe section of the report, lessons were not effectively learnt when failures occurred in people’s care. This meant people continued to be at risk of poor care.

Issues that had been identified prior to our inspection such as responding to people’s deteriorating health, working in partnership with health professionals, engaging with people effectively and care planning were still ongoing at the time of our inspection. This demonstrated a lack of improvement.