Lessons Learnt Briefing SoT Nursing home closure

Learning from reviews to improve practice: Short notice closure of the Nursing section of a Nursing and Care Home

In August 2017 there was considerable and serious professional concern about the nursing unit of a Care Home in Stoke-on-Trent. This led to the regulator, the Care Quality Commission (CQC,) arranging an urgent inspection which in turn led them to requiring the immediate closure of the nursing unit of the home. A combination of health and social care agencies were involved in the practical arrangements to achieve this. They worked alongside the owners and staff of the home. Both nursing and social care staff were allocated to arrange urgent assessments of all residents while other staff were involved with informing relatives and staff at the home. The third element was identifying alternative and available placements that would meet the needs of each individual resident.

The task was completed within less than a week and overall the transfer and outcomes achieved were considered to be a success. However, there was universal concern from those involved that although the outcomes were largely positive the process of arriving there was confusing and at times chaotic. There was a view that, despite substantial goodwill and energy from staff from all agencies, the result was in part fortunate and there was little confidence that in a similar future event such a positive outcome could be guaranteed. The Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board decided to commission an independently led Multi-Agency Learning Review from which to identify lessons to be learned and to improve future processes and practice.

Areas of good practice:

  • Despite the at times chaotic response to the fast-paced situation there was excellent collaborative working by all involved agencies, including working with partners across geographical boundaries. There was a tangible desire and will to make things happen as quickly and as effectively as possible in a very challenging situation
  • The willingness of the Care Home owners to participate in the Multi-Agency Learning Review
  • Acknowledgement by all that there are areas for improvement and a willingness to work together to achieve this for the benefit of future similar situations Areas for improvement:
  • The SSASPB partners are to consider how WMAS data about frequency of incidents at a care or a nursing home could be used to prevent incidents of abuse and neglect
  • To seek assurance that Commissioners of care have appropriate mechanisms to share both hard and soft information about nursing and care homes that is informed by, and in turn informs, front line staff
  • The local partnership of the Council, NHS agencies and the CQC should have an agreed written process to support the short-term closure of homes and that staff are aware of this. The policies should reflect national good practice.
  • The guidance is to include how the Police may capture evidence with which to consider any criminal justice process.
  • The local partnership should consider testing the procedures, for example by using simulated exercises, to further identify improvements.