CQC report explained · a residential care home
What the CQC found at Norcott House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Infection control was not always managed effectively at the first visit, although action was taken during the inspection. Risk assessments were not always known or followed, and incident records did not always explain outcomes or learning.
- Effective?
- Good
- The report does not give a rating for Effective because this focused inspection covered Safe, Responsive and Well-led.
- Caring?
- Good
- The report does not give a rating for Caring. Inspectors found staff were kind and patient and treated people with dignity and respect.
- Responsive?
- Requires improvement
- Care plans were person-centred in style, but did not always reflect people's needs or choices. Staff did not always follow agreed behaviour support plans, and activities were sometimes restricted by staffing or medication arrangements.
- Well-led?
- Requires improvement
- The management team was established and supportive, but audits did not always identify or address problems. Oversight of risks, incidents, safeguarding and staff concerns was not consistently thorough.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found kind care and enough staff, but concerns about infection control, risk management and personalised support.
Inspectors visited on 25 February, 6 April and 25 April 2022. The first visit was announced and the later visits were unannounced. They spoke with people, staff, relatives and advocates, observed care and reviewed care, medicines, staff and management records.
The home had enough staff and followed safe recruitment procedures. Staff were kind and patient, communication was adapted to people's needs, and people were supported with activities, family relationships and community visits. Medicines were managed safely overall.
However, infection control was not being followed properly at the first visit. Some risk assessments and behaviour support plans were not followed, incident records lacked detail, and quality checks did not always find problems. The home took action during the inspection to improve cleanliness, PPE use and medicine storage.
The overall rating was Requires Improvement. Safe, responsive and well-led were all rated Requires Improvement. The report does not give ratings for Effective or Caring. The previous rating was Good, published on 5 April 2018.
Enough staff
Inspectors found enough staff to meet people's care needs, and relatives and advocates also felt staffing levels were safe. Recruitment checks were completed properly.
“There were enough staff to support people's care needs.” from the report
Kind and respectful care
Staff were described as kind, patient and respectful. People were supported with dignity, privacy, independence and family relationships.
“Staff were kind and patient and said they supported people in the least restrictive way possible and in their best interests.” from the report
Accessible communication
Staff used gestures, signs, visual choices and easy-read information to help people communicate and make decisions.
“Staff skilfully communicated with people when people had limited verbal abilities, using gestures, signs and visual choices.” from the report
Community activities and relationships
People were supported to take part in activities, go into the community and maintain relationships. Staff knew people's likes and dislikes.
“Staff developed good relationships with people, knew their likes and dislikes and interaction was consistently positive and attentive.” from the report
Action during inspection
The management team responded promptly to the infection control concerns raised on the first day and took action to improve cleanliness and PPE use.
“The management team responded promptly when we raised concerns about IPC on day one of the inspection.” from the report
Infection control
seriousThe infection control policy was not being followed in practice at the first visit. Cleaning, premises hygiene and PPE use raised concerns, although the home acted during the inspection.
“Risks associated with infection prevention and control (IPC) were not always effectively managed.” from the report
Risk and behaviour plans
seriousStaff did not always know or follow people's risk assessments and behaviour support plans. This included differences in how staff responded to distress and the use of physical holding that was not recorded in the care plan.
“People were not always appropriately supported to manage their behaviour and plans were not always reflective.” from the report
Incident learning
needs fixingIncident records did not consistently include outcomes, debriefs or details of how future incidents would be prevented. Inspectors recommended more detailed debriefs after every incident.
“Incident records lacked detail, such as outcome and debriefs, and so there were missed opportunities for the service to learn and help prevent re-occurrence.” from the report
Quality checks
needs fixingThe home's audits did not always identify or address problems. The report also found weak oversight of incidents, safeguarding concerns and staff concerns.
“There needed to be clearer and more robust quality assurance systems within the home and oversight of risk.” from the report
Choice and activities
minorActivity plans did not always reflect people's choices. Activities could be restricted by staffing and medication arrangements, and some recorded preferences were not followed.
“On occasion, people's preferences did not always appear to be followed.” from the report
Medicines details
needs fixingMedicines were managed safely overall, but one medicines room door was unlocked, one storage temperature was outside the recommended range at times, and some as-required medicine instructions were not specific enough.
“Instructions for medicines that are given when required (PRN) were not always person centred.” from the report
- 01How do you make sure every member of staff knows and follows my relative's current risk assessment and behaviour support plan?
- 02What changes have you made since the inspection to prevent infection control problems, and how do you check that staff follow them?
- 03How are incidents debriefed with the person affected, and how are possible triggers and lessons recorded?
- 04How do you make sure activities reflect each person's preferences and are not restricted by staffing or medication arrangements?
- 05What improvements have you made to quality audits and oversight of safeguarding concerns, accidents, incidents and staff concerns?
This started as a targeted infection prevention and control inspection and was widened to a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not rated. This explanation was written from the published report of 21 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, April 2018
Rated Good; inspectors found safe, kind and personalised care, but medicines and complaint records needed improvement.
Inspectors visited the home on 12 and 13 February 2018. The first day was unannounced. They spoke with people, relatives, staff and healthcare professionals, observed care and checked care, medicines, staff and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, robust recruitment checks, detailed care plans, staff training and good access to healthcare.
People were supported to make choices, stay independent, take part in activities and keep in touch with relatives. Staff were described as kind and respectful, and the home had systems for checking quality and learning from incidents.
There were some shortfalls. Some topical medicines had not been recorded on medicines charts, and staff had changed some medicines records without the required prescriber changes. One complaint had not been fully recorded. The manager took prompt action on the medicines issues.
Kind and respectful staff
Inspectors observed supportive care and staff who knew people's likes, dislikes and communication styles. People said their privacy and dignity were respected.
“People told us staff were caring and respectful of their privacy and dignity.” from the report
Support for independence
People were encouraged to cook, do laundry, manage domestic tasks and make choices about their daily routines. Equipment had also been provided to help one person shower independently.
“Support workers promoted people's independence.” from the report
Activities and family contact
People could choose from activities at home and in the community, including shopping, walks, meals out, work experience and holidays. Staff also supported contact with relatives.
“People had access to a range of person-centred activities.” from the report
Staffing and training
Inspectors found enough staff to meet people's needs. Staff had induction, specialist training, regular updates and supervision.
“Support workers received the training and supervision they needed to provide people with effective care.” from the report
Quality monitoring
The home used several audits and feedback methods. The provider also reviewed audit results, incidents and learning across its services.
“A comprehensive system of audit and monitoring was in place at Norcott House.” from the report
Medicines records
needs fixingSome topical creams were recorded on separate forms rather than medicines charts. Staff had also amended some charts without evidence that a qualified prescriber had made the changes. The manager took immediate action, and inspectors found no evidence that people had been supported unsafely.
“However, we identified some issues with the recording of medicines administration in one of the two buildings which comprised the home.” from the report
Accessible information work
minorCare plans included detailed communication information, but the home was still working towards meeting all parts of the Accessible Information Standard. Inspectors said this would be checked at the next inspection.
“We will check the service meets all other aspects contained within the AIS at the next inspection.” from the report
- 01How are topical creams and all other medicines recorded now, and who checks the medicines charts?
- 02What has changed to prevent staff making unauthorised changes to medicines records?
- 03How are complaints recorded, investigated and communicated back to the person who raised them?
- 04Has the work on the Accessible Information Standard been completed, and how are people's communication needs recorded?
- 05How are each person's food preferences and activity choices reviewed with them?
This was an inspection of all five CQC areas and the overall quality of the home; the first day was unannounced. This explanation was written from the published report of 5 April 2018 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 Norcott House
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- July 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2018Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 20 January 2012.
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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