CQC report explained · a residential care home
What the CQC found at Norbury Hall
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, and risks, medicines, staffing, recruitment and infection control were managed well overall. One pressure-relieving mattress was not at the correct setting for the person's body weight.
- Effective?
- Good
- Care plans were based on people's needs and kept up to date. People received support with healthcare, food and drink, staff training and decision-making in line with the law.
- Caring?
- Good
- Staff treated people with dignity and respect and developed good relationships with them. People were encouraged to take part in their care and express their choices.
- Responsive?
- Good
- Care was personalised around people's needs, preferences, backgrounds and routines. People were supported to keep in touch with relatives, take part in activities and raise complaints.
- Well-led?
- Good
- The home had approachable leadership, effective audits and a positive culture. The manager understood their responsibilities and the home had corrected the previous failure to display its CQC rating.
What inspectors found, June 2022
Norbury Hall is rated Good; inspectors found kind, safe and personalised care, with one pressure mattress not always set correctly.
Inspectors made an unannounced visit on 10 May 2022. They spoke with people living at the home, relatives, staff and health and social care professionals. They observed care and checked care, staff and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were supported with medicines, healthcare, food, activities and personal care. Staff were described as kind, approachable and knowledgeable about people's needs.
There was one shortfall. A pressure-relieving mattress was not set correctly for one person's body weight, although this had not caused harm. The manager said this would be corrected immediately.
The previous rating was Requires Improvement, with breaches of regulations. Inspectors found that improvements had been made and the home was no longer in breach. The inspection was also prompted by concerns about restraint, but inspectors found these were no longer a concern.
Kind and respectful staff
People were comfortable with staff, who were described as kind, caring and approachable. Staff were not rushed and had time to engage with people.
“We observed staff developed good relationships with people and people were comfortable approaching staff and talking with them.” from the report
Personalised care
Care plans reflected people's health needs, backgrounds, personalities and preferences. They were kept up to date for staff to follow.
“People's care plans were person-centred. They detailed people's health needs, backgrounds, personalities, those who were important to them and how they preferred to receive their care.” from the report
Safe medicines support
Medicines were checked and administered by trained, competent staff. Records and stock levels were as expected.
“We found stocks of medicines and medicines records were as expected which meant people received their medicines as prescribed.” from the report
Improved staffing
The provider had increased staffing numbers, including activities, domestic and kitchen staff, to meet people's needs. Recruitment checks were robust.
“There were enough staff to support people safely and the provider had increased staffing numbers in line with people's needs.” from the report
Good health and food support
People were supported to attend healthcare appointments and received food and drinks suited to their choices, dietary needs and cultural preferences.
“We observed a mealtime and saw people received food of their choice and specific dietary requirements and cultural needs were met.” from the report
Pressure mattress setting
needs fixingOne pressure-relieving mattress was not set to the correct setting for the person's body weight. Inspectors said this had not caused harm, and the manager said it would be improved immediately.
“However, we found risks could be reduced further as one pressure relieving mattress was not at the right settings relating to body weight.” from the report
Further dementia training planned
minorSeveral people were living with dementia relating to substance abuse. The provider planned to add this subject to its staff training programme, so families may want to check whether this has happened.
“Several people were living with dementia relating to substance abuse and the provider planned to include this in their training programme.” from the report
- 01Was the pressure-relieving mattress reset immediately, and how do you now check that mattresses are set correctly for each person's needs?
- 02How many permanent, agency and newly recruited staff are currently working at the home, and has the ongoing recruitment been completed?
- 03Has the planned training about dementia relating to substance abuse been added to the staff training programme?
- 04What improvements to signage, colour schemes and memory boxes have been completed to help people with dementia find their way around the home?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control measures; the inspection activity took place on 10 May 2022. This explanation was written from the published report of 24 June 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, August 2019
Rated Requires Improvement; inspectors found kind, respectful care, but risks, food choices and management systems were not consistently handled.
Inspectors visited without notice on 12 and 13 June 2019. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
There had been improvements since the previous inspection. These included safer medicine storage, better staffing at night, easier-to-clean flooring and more accessible emergency pull cords. However, some risks were not recorded properly, including falls and weight loss.
People were positive about staff and the care was rated Good for Caring and Responsive. Food choice and access to snacks and drinks were limited. Kitchen hygiene also needed improvement, and the home had not displayed its previous CQC rating.
The overall rating remained Requires Improvement. Safe, Effective and Well-led were also Requires Improvement. The home was still in breach of regulations, so CQC required an action plan and said it would monitor progress and reinspect.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw staff protecting people's privacy and treating them respectfully.
“People were supported and treated with dignity and respect; and supported people to express their views.” from the report
Improved environment
The home had made environmental changes that reduced some infection risks and made emergency call cords easier to reach.
“Emergency pull cords were the correct length and easily accessible for people should they need them.” from the report
Improved night staffing
More skilled staff were available at night, and the home was no longer in breach of the staffing regulation. Inspectors still wanted staffing numbers to be based on people's needs.
“At this inspection we found enough improvement had been made and the provider was no longer in breach of regulation 18.” from the report
Activities and relationships
The home provided organised activities and people had positive relationships with one another. People wanted more outings, but inspectors saw people taking part in activities and spending time together.
“People formed positive relationships with each other.” from the report
Mental capacity practice
Staff understood the need to seek consent and make best-interest decisions when required. Applications for restrictions on liberty had been properly made and authorised.
“The service was compliant with the MCA.” from the report
Risk records were incomplete
seriousThe move from paper records to an electronic system was not reliable. At least five people's falls were missing from the falls analysis, and weight-loss information was inconsistent.
“At least five people who had fallen were not recorded on the analysis.” from the report
Limited food and drink choices
seriousPeople did not always have a genuine choice of meals, snacks or drinks. Healthy snacks were not readily available, including for people who might forget to ask.
“Healthy snacks and drinks were restricted and not readily available unless people asked for them.” from the report
Kitchen hygiene
needs fixingCleaning records lacked detail, some opened foods were stored incorrectly and the kitchen hand-washing facilities had a broken cold-water tap and no paper towels.
“We recommend the provider consult best practice in relation to infection control and food hygiene in care homes.” from the report
Management oversight
needs fixingThe new management team was working on improvements, but relatives did not always know who the managers were or feel listened to. The CQC rating was also not displayed as required.
“This meant it was not obvious for people using the service and their family members or people looking at their website that Norbury Hall required improvement.” from the report
Incomplete care planning
needs fixingCare records varied in detail. Not everyone had been involved in discussing their end-of-life wishes, and some information was missing from records.
“During this inspection we found not everyone had been involved in discussing their end of life plans and some information was not complete in people's care record's.” from the report
- 01How have you checked that every person's falls, weight loss and other risks are now recorded accurately in the electronic care system?
- 02What food and drink choices, including healthy snacks, are available outside set mealtimes, and how do you support people who may not ask?
- 03How are staffing numbers worked out from people's individual needs, especially at busy times and overnight?
- 04How do you now check kitchen cleaning, food storage and hand-washing facilities?
- 05How are families involved in care reviews and discussions about end-of-life wishes?
This was an unannounced planned inspection based on the previous rating and covered all five key questions, including the premises and care provided. This explanation was written from the published report of 6 August 2019 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 Hall
5 rated inspections over 7 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
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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