CQC report explained · a nursing home
What the CQC found at Norbury Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2022
Norbury Court rated Requires Improvement; inspectors found serious gaps in medicines, risk management and oversight.
This was an unannounced focused inspection on 15 and 16 June 2022. Inspectors spoke with people living there, relatives, staff and a visiting health professional. They also checked care records, training information and quality checks.
The home was not always safe or effective. Medicines records were incomplete, some medicines were not available, and staff did not always record medicine times and doses. Care plans and monitoring did not always give staff enough information about people's health needs. Infection control and cleanliness also needed improvement.
The home had quality checks, but they had not led to enough action. Some problems found during the inspection had already appeared in earlier checks. Inspectors also heard that staffing levels could make it harder to meet people's care needs and choices.
The overall rating was Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. Caring and Responsive were not inspected at this visit, so their previous ratings were used in the overall rating.
Safeguarding awareness
People were protected from abuse, and staff knew what to do if they saw poor practice. Safeguarding procedures were used appropriately.
“People were protected from the risk of harm and abuse.” from the report
Health professional support
People were supported to see appropriate health and social care professionals. Referrals and visits were described as timely.
“People were supported to see appropriate health and social care professionals when they needed to meet their healthcare needs.” from the report
Support for choice
Staff supported people to make choices and to be as independent as possible. The service generally used the least restrictive approach.
“Staff described how people were promoted to be as independent as possible and to make decisions for themselves.” from the report
Open management response
The management team accepted the problems identified and said they were taking steps to improve safety and quality.
“The registered manager was honest and open with us.” from the report
Medicines records and supply
seriousMedicine administration records were incomplete or inaccurate. Some medicines were not available, and records did not always show when creams or time-sensitive medicines had been given.
“Medicines were not always managed safely across the home, which placed people at risk of harm.” from the report
Health risks and care plans
seriousCare plans did not always explain people's medical needs or the care required. Staff did not consistently complete monitoring and some PEG and repositioning tasks were not recorded as required.
“Risks to people's health, safety and wellbeing were not managed safely.” from the report
Governance did not drive improvement
seriousAudits had identified some concerns, but there was little evidence that action had been taken. The same problems appeared again, and some problems were missed altogether.
“The systems in place to monitor the service were not effective.” from the report
Infection control and cleanliness
needs fixingSome carpets, furniture and equipment were dirty or damaged, and parts of the home were unpleasant. Staff also lacked hand-washing facilities in one kitchen area.
“However, on the day of the inspection, parts of the environment were malodorous and unpleasant to live in.” from the report
Staffing and supervision
needs fixingPeople and staff reported that more staff were needed at times. Staff did not always receive regular supervision, appraisal or observation while working.
“People and staff reported they felt more staff were needed to meet people's wishes and choices.” from the report
- 01What has changed in the way medicines are supplied, administered and recorded since the inspection?
- 02How are nurses now checked for competence in medicines, PEG care and clinical monitoring?
- 03How do you make sure care plans contain clear instructions for seizures, PEG care, nutrition, hydration and pressure ulcer prevention?
- 04What action has been taken to improve cleaning, damaged surfaces and hand-washing facilities?
- 05How many staff are normally on each shift, and what happens when staff are absent or the home has extra care needs?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 14 July 2022 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, March 2021
Inspected but not rated; inspectors found strong infection prevention and control arrangements during the COVID-19 pandemic.
Inspectors visited the home on 10 March 2021. This was an announced, targeted inspection carried out as part of the response to the coronavirus pandemic.
They looked at infection prevention and control. They found visitor screening, temperature checks, PPE requirements, testing, vaccination, cleaning, infection control audits and extra staff training in place.
The home had arrangements for safe indoor and outdoor visits, including separate visiting rooms and safer visits to people's rooms in exceptional circumstances. Zoning was used when people tested positive and needed to self-isolate.
The home was rated inspected but not rated. The inspection did not provide an overall quality rating or ratings for the other four areas.
Visitor safety
Visitors were screened on arrival, had temperature checks and were required to use PPE. The home had separate rooms for visits where possible.
“All visitors underwent screening checks on arrival and were directed to wear PPE before being able to enter the service.” from the report
Safe visiting arrangements
The home had arrangements for indoor and outdoor visits. It also made safer visits possible for people receiving end of life care or being nursed in bed.
“The home had a robust process in place for facilitating indoor or outdoor visits.” from the report
Clean environment
Inspectors found the home clean and tidy. Domestic and care staff completed scheduled infection control tasks, and audits were used to check standards.
“We found Norbury Court to be clean and tidy.” from the report
Managing infection risks
The home used zoning for people who tested positive and had testing in place for people living there and staff. Staff had also received extra infection control training.
“Zoning arrangements were used when people had tested positive for COVID-19 and needed to self-isolate in certain areas of the home, such as bedrooms.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now?
- 02How are visits currently organised, including visits to people's rooms in exceptional circumstances?
- 03How are people and staff tested if there is a suspected or confirmed infection?
- 04How would the home manage an infection outbreak or ask someone to self-isolate?
- 05What other CQC reports or ratings cover care that this inspection did not assess?
This was a targeted inspection of infection prevention and control as part of the coronavirus pandemic response; the service was inspected but not rated and the other four areas were not assessed. This explanation was written from the published report of 23 March 2021 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 Norbury Court
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- July 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- August 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- April 2013
Registered with the Care Quality Commission on 16 April 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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