Things Fall Apart.....

Well, not quite. But the Review was quite frustrating. 

I have spoken of the Good Nurse before. She is intelligent and enthusiastic (she regularly requests night shifts so she can catch up with her paperwork) and she is committed to Rosemarie. The Psychiatric Nurse from the Community Mental Health Team likes dealing with her and actually rescheduled the planned Review Meeting so it coincided with a day she was working so she could attend.

She was transferred to a different floor at the last moment so could not attend the meeting. 

Now the nurse who was on duty is not a bad person, but she has only been working at the Care Home for three months and only worked on Rosemarie's floor for a handful of days. There was no way she could know Rosemarie well enough to input to the meeting and she had no time to prepare for the meeting so none of the required notes were easily available. 

The main purpose of the meeting was to review the medication and the care plan based on the data recorded by the one-to-one carers about her emotional and mental state. This meant reviewing the effect of the changes in her medication on upset and agitation and sleep pattern. Guess what.

The quality of the data left a lot to be desired. The carer notes (which may or may not be what is sent to the CCG - I hope not) often consisted of nothing more than "Sitting in Lounge" or "Taken to room and changed"

So no information from the Home about her emotional state. Sleep chart? Not in the file. The nurse had to go and look for it. Interesting point here. The sleep chart ends at 0800. I am told when I ask that Rosemarie is often sleepy in the mornings - woken up for breakfast but then left to sleep till 1030 or 1100. This cannot be recorded on the sleep chart, so is it recorded in the carer notes?

Take a wild guess.

The notes are not done during the day as events unfold. They are completed at the end of the day by a designated carer who may or may not have been with Rosemarie for any significant period during the day. They try their best and as far as I can tell do it studiously but this is a recipe for bad data. I noticed it when I reviewed the information used by the nutritionist to make a decision on Rosemarie's dietary needs. The chart showed that in the previous week she had eaten all of her supper every day. This came as a surprise to me since I had given her supper each day that week and knew for a fact that she hadn't eaten all of it. Nor had anybody asked me what she had eaten. 

So I started to record relevant data about my time with Rosemarie on my own form each day and the Good Nurse was keen to include this in Rosemarie's notes. This has now become the pattern. The Psychiatric Nurse commented in the meeting that these were the only notes that were useful in making a decision. She took copies away.

It seemed clear to me that there was no point in asking the Duty Nurse to do anything, even though she was attentive and scribbled things down. There is no reliable way of feeding change into the system with any certainty it will be applied. 

The Care Home has a Manager who can set policies and make decisions, but is far to busy to monitor the results except in the short term where there is a strong impetus (concerned relatives). This focus of attention will naturally fade with each successive meeting with different concerned relatives.

The next management layer down is the Care Manager, who is basically fighting fires and unless there is a major problem with Rosemarie is unlikely to have more than a passing contact every so often. Even if notes were comprehensive neither of these individuals would have the time to check up on every resident. I was told about six months ago that there was a plan to have regular reviews of the care plan with relatives at least every three months. Still waiting.

The next layer down is the Duty Nurse. I am not privy to shift handover meetings but the evidence I have suggests only really significant information is communicated or absorbed. The Duty Nurse has the power to effect change because they are responsible (it seems) for the management of the Care Workers, but whether this power is used or not seems to depend on the attitude and confidence of the nurse on duty. Good Nurse is quite happy to tell Care Workers what to do; others less so. In the absence of strong management the Care Workers become a self governing democracy influenced by the strongest personality. I have seen this quite a lot - the Duty Nurse is a resource for escalating problems or delegating decisions (can you delegate a decision upwards?) Having what is in effect a Supervising Care Worker may be a practical solution but it increases the complexity of the information flow. Care Workers and Duty Nurses work shifts, have breaks, and have days off. 

Case in point. Rosemarie has one-to-one care. That means that there should be someone with her at all times looking after her interests and taking her out of stressful situations. On a busy day, even with the optimal staff complement, there is a tendency for the Care Workers to behave as if it is OK if only one of them is in the lounge keeping an eye on the residents, even though that one should be dedicated to Rosemarie. You can see where this is going. One-to-one care gets diluted. Even if there are two workers in the room, who managerially decides to take Rosemarie out of a stressful situation? What are the chances that any two randomly selected Care Workers will know what the policy is and how to apply it?

To give Duty Nurse credit, she took this on board. The next day when I came in she was on duty and told me that Rosemarie had been tearful during the afternoon and one of the Care Workers had been told to take her somewhere quiet and sit with her. I found her in the garden. 

So. Tiny victories and oiling the machine one component at a time. 

The Psychiatric Nurse will be phoning the Care Home Manager. I will let that happen then request a meeting. 

I must stress that these are not bad people and this Care Home has an excellent reputation and is by far the best one we visited.

I am not complaining about the Care Home.

I am complaining about the world.