CQC report explained · a residential care home
What the CQC found at 135 Norman Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing, recruitment, risk assessments, medicines and infection control were found to be suitable, although some water was very hot and the thermometer could not measure its exact temperature.
- Effective?
- Good
- Support plans were personalised and staff had the training and knowledge to meet people's needs. People were supported with food, healthcare, communication and decisions about their care.
- Caring?
- Good
- Staff treated people with kindness, patience, dignity and respect. People were supported to make choices, express themselves and develop independence.
- Responsive?
- Good
- Care was planned around people's individual needs, goals and communication styles. People were supported with activities, relationships, daily living skills and access to the community.
- Well-led?
- Good
- The management team was described as responsive and approachable. Audits, feedback and reviews were used to monitor the quality of care and make improvements.
What inspectors found, August 2023
135 Norman Road is Rated Good; inspectors found safe, kind and personalised care, with some decoration and water temperature issues.
The inspection was unannounced. One inspector visited on 27 June 2023, and inspection activity ended on 20 July 2023. The inspector reviewed care plans, risk assessments, medicines records, recruitment files, audits and other records. They also spoke with one person, two family members and four staff.
The home supports up to three people with learning disabilities, autism or mental health needs. All three places were occupied. Inspectors found suitable staffing, safe medicines support, personalised care plans and staff who understood people's communication and support needs.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home was also rated Good overall. Inspectors recommended improvements to decoration because some communal areas looked worn. They also found that some water was very hot, but the manager acted during the inspection.
Familiar staff
People were supported by regular staff who had worked at the home for a long time and knew their needs well.
“People told us they were supported by regular and familiar care staff and cover arrangements were in place.” from the report
Personalised support
People helped shape their support plans and could make choices about their care, rooms, activities and daily lives.
“The provider implemented a person-centred support plan approach, which meant that people were involved in taking control of their lives.” from the report
Kind and respectful care
Inspectors saw positive interactions. Staff supported people's privacy, dignity, communication and independence.
“During the inspection, we saw that staff were patient and used appropriate interaction and communication with people.” from the report
Safe medicines support
Medicines records were completed correctly by trained staff. People received support with decisions about medicines and regular reviews by health professionals.
“We checked people's medicine administration records (MAR) and saw these had been correctly completed by trained staff.” from the report
Good management oversight
The home used audits, spot checks, feedback and incident reviews to monitor care and identify learning.
“During the inspection, we looked at the provider's governance system, which worked effectively and helped improve the running of the service.” from the report
Communal areas needed decoration
needs fixingInspectors found that some communal areas looked worn and recommended following best practice guidance to bring the home to a suitable decorative standard.
“We identified that the communal areas were in needs of some decoration.” from the report
Water temperature checks
needs fixingThe kitchen and one person's hot water were very hot. The manager reported the issue and ordered a new monitor during the inspection, but families should ask for an update.
“During the inspection, we identified that the kitchen and one person hot water temperature was very hot however we were unable to get the exact temperature as the provider's thermometer only went to the 50°C.” from the report
- 01What work has been done to decorate the dining room, hallway and other communal areas?
- 02What were the final hot water temperature readings after the new water monitor was obtained?
- 03How often are water temperatures now checked and recorded?
- 04How are people involved in reviewing their support plans and risk assessments?
- 05How are people's daily activities and community access reviewed to make sure they still match their goals?
This unannounced inspection looked at all five key questions, including infection prevention and control under Safe, and the ratings remained Good compared with the December 2019 inspection. This explanation was written from the published report of 3 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2020
135 Norman Road: Rated Good; inspectors found kind, safe and person-centred care, but the home needed modernising.
This was a planned inspection on 16 December 2019. One inspector spoke with all three people living at the home, three staff members and reviewed care, medicine, recruitment and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were supported by kind staff who respected their choices, privacy and independence.
The home had suitable systems for managing risks, medicines, staff training, care planning, complaints and quality checks. Inspectors found some minor environmental problems, including dated communal areas, a damaged kitchen worktop and dust and cobwebs in two areas.
Kind and respectful care
Inspectors saw staff spending time with people and treating them as individuals. People's privacy, dignity, cultural needs and independence were supported.
“People were supported by kind and caring staff who treated people as individuals and with dignity and respect.” from the report
Personalised support
Care plans included people's histories, interests, preferences and communication needs. People were involved in planning and reviewing their care.
“People's care plans contained their communication needs, preferred communication methods, and instructions for staff on how to communicate effectively.” from the report
Activities and community links
People were supported to take part in activities that matched their interests, including day centres, swimming, places of worship, shopping and holidays.
“People's organised activities were based on their preferences.” from the report
Safe staffing and medicines
Inspectors found appropriate recruitment checks, enough staff and safe systems for storing, administering and recording medicines.
“Medicine Administration Records (MARs) were completed and audited appropriately.” from the report
Strong management checks
The provider used regular checks covering medicines, the environment, records and other areas of service quality.
“The service had a number of effective quality monitoring systems in place.” from the report
Communal areas needed updating
needs fixingThe lounge, dining room and hall had not been decorated or updated for a long time. The kitchen sink sealant had deteriorated and had damaged the worktop.
“The communal lounge, dining room and hall entrance had not been decorated and updated for a long period of time.” from the report
Cleaning detail
minorThe home was generally clean, but inspectors found dust and cobwebs in the laundry room and a toilet. The manager said these areas would be deep cleaned, and later said they had been cleaned.
“However, the laundry room and toilet at the back of the home had cobwebs around the window and a build-up of dust.” from the report
Lessons from incidents
needs fixingAccidents and incidents were recorded and acted on, but the provider did not record lessons learned. The manager said this would be reviewed.
“The provider did not record lessons learnt. We discussed this with the registered manager who told us they would review, and record lessons learnt moving forward.” from the report
- 01Have the damaged kitchen worktop and deteriorated sink sealant been repaired?
- 02What changes have been made to the communal lounge, dining room and hall, and how were people involved in choosing them?
- 03How do you now record and share lessons learned after accidents or incidents?
- 04How do you make sure the laundry room and toilet remain free from dust and cobwebs?
- 05How are people's activities, communication preferences and care plan reviews kept up to date?
This was a planned, announced inspection covering all five CQC questions, and both the premises and the care provided were looked at. This explanation was written from the published report of 1 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 135 Norman Road
4 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- May 2013
Registered with the Care Quality Commission on 29 May 2013.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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