CQC report explained · a residential care home
What the CQC found at Norcrest
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and improper treatment, risks were assessed and staffing levels were considered sufficient. Inspectors identified an undetected pharmacy error and no suitable water hygiene risk assessment at the time of the visit.
- Effective?
- Good
- Staff received induction, training, supervision and appraisals. However, the provider had not completed all necessary mental capacity assessments and had not yet referred some people for speech and language assessment linked to choking risk.
- Caring?
- Good
- Staff were observed to be attentive, kind and respectful. People were supported with communication, privacy, dignity and independence, although information about body weights had briefly been displayed publicly and was removed during the inspection.
- Responsive?
- Good
- Care plans reflected people's personal histories, preferences, interests and aspirations. People were supported with activities, relationships, visits, holidays and end of life choices.
- Well-led?
- Good
- Leadership was described as visible and capable. Regular audits, meetings and feedback systems were in place, and the report found detailed and accurate records.
What inspectors found, February 2018
Rated Good overall; inspectors found kind, personalised care, but some capacity, choking-risk and safety checks needed attention.
The inspection was unannounced and took place on 22 January 2018. One inspector spoke with a person using the service, relatives, the registered manager and care workers. They also looked at care records, staff files, medicines records and other records.
The home supported 11 people with learning disabilities and/or autism. Inspectors found people were safe, treated with kindness and supported by staff who understood their needs. Care plans were personal and included people's communication needs, choices, interests and goals.
The home was rated Good for Safe, Effective, Caring, Responsive and Well-led, as well as Good overall. This was the same rating as at the previous inspection in August 2015. Inspectors also found some areas needing action, including mental capacity assessments, choking-risk referrals, medicines checks and water safety records.
Kind and respectful staff
Inspectors saw staff being attentive and kind. Relatives and staff also described positive relationships and respectful support.
“During out inspection we observed staff were attentive and kind to people.” from the report
Support for independence
People were supported to develop everyday skills such as cooking, cleaning, laundry and travelling safely in the community.
“Staff told us how they encouraged people to take part in household chores to increase their independent living skills such as cooking, cleaning and laundry.” from the report
Activities and relationships
People had activity programmes based on their interests and were supported to keep in touch with relatives and maintain relationships.
“Each person had an activity programme in place based on their interests.” from the report
Active management
The provider used regular audits and action plans to identify and improve shortfalls. Staff and relatives said the registered manager was approachable.
“The provider had systems in place to audit and improve the service.” from the report
Incomplete capacity assessments
needs fixingThe provider had not completed all mental capacity assessments needed for decisions about medicines and personal care. The manager said these would be arranged as soon as possible.
“However, the provider had not carried out all mental capacity assessment necessary for people.” from the report
Choking-risk referrals pending
seriousSome people may have been at risk of choking, but speech and language assessments had not yet been requested. Staff were using precautions while people ate.
“However, the provider had not referred people for a speech and language therapy (SALT) assessment.” from the report
Medicines checking error
needs fixingStaff records showed medicines were administered accurately, but staff did not notice that two tablets were missing from a pharmacy delivery. The manager said the checking process would be improved.
“However, although two staff checked medicines received by the pharmacy we identified staff had not identified a pharmacy error.” from the report
Water safety assessment
needs fixingThe home did not have a suitable water hygiene risk assessment during the inspection, although a contractor checked water safety each year.
“We identified the provider did not have a suitable water hygiene risk assessment in place” from the report
Privacy of weight information
minorPeople's body weights had been displayed on a dining-area wall. The provider removed the information immediately after inspectors raised the concern.
“However, the provider had put information about people's body weights on the wall of the dining area which meant this information was not treated confidentially.” from the report
- 01Have all outstanding mental capacity assessments now been completed, including for medicines and personal care?
- 02Which people were referred for speech and language assessment because of possible choking risk, and what guidance is now in place?
- 03What new checks are used when medicines arrive from the pharmacy?
- 04Has a suitable water hygiene risk assessment been completed, and have any recommended control measures been put in place?
- 05How do you make sure personal information, including people's weights, is kept confidential?
This was an unannounced inspection covering all five key questions and the overall service; the previous overall rating in August 2015 was also Good. This explanation was written from the published report of 17 February 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 Norcrest
2 rated inspections over 2 years: the service has held its Good rating throughout.
- February 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 30 August 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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