CQC report explained · a residential care home
What the CQC found at Normandy 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
- Some care plans, risk records and hospital assessments were out of date or did not cover known risks. Medicine recording also needed improvement, although staff were trained and people received their medicines as prescribed.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks were not always completed on time or effective enough to find problems. Some care records and do-not-resuscitate information also needed better management oversight.
What inspectors found, October 2021
Normandy House was rated Requires Improvement because inspectors found gaps in risk records, medicines records and quality checks.
This was an unannounced focused inspection on 8 September 2021. Inspectors looked only at Safe and Well-led, after concerns were raised about management and staff practices. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was not always safe because some care and hospital records did not reflect people's current risks. Medicine records also needed strengthening. Inspectors found no negative impact on people from these recording problems, and the manager said the records had been updated after the inspection.
The home was not always well-led. Audits were late or did not identify issues such as an out-of-date medicine, cleaning problems and records needing review. Inspectors also found that information about some do-not-resuscitate decisions was not consistent or clearly linked to discussions with relatives.
There were also positive findings. People were supported by a consistent staff team, staff recruitment checks were in place, infection control arrangements were suitable, and relatives generally felt people were safe and listened to. The overall rating fell from Good to Requires Improvement, while ratings for the other three questions were carried forward from the previous comprehensive inspection.
Consistent staffing
There were enough staff to meet people's needs, and the home used a permanent team rather than agency staff.
“There were sufficient staff available to ensure people's support needs were met.” from the report
Safe recruitment
The provider carried out checks to make sure staff were suitable for their roles.
“The provider followed safe recruitment practices.” from the report
Positive care
Inspectors observed warm, person-centred interactions. Staff supported people to make choices and start activities again after pandemic restrictions eased.
“All of the feedback we received, and our observations, confirmed staff put people at the centre of the service and provided good quality care that focussed on their care needs.” from the report
Infection control
Inspectors were assured about the home's arrangements for PPE, testing, visitors, social distancing and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Out-of-date risk records
seriousSome records did not describe current risks, including choking risks, use of a lap belt and emotional distress. This meant there was an increased risk of unsafe care.
“A range of care and risk support plans were in place but were not always up to date and did not cover all known risks.” from the report
Medicine recording
needs fixingGuidance for medicines given when needed was limited, and records did not always explain why medicines were not given or follow best practice.
“Some areas of medicine documentation required strengthening.” from the report
Weak quality checks
needs fixingSome audits were late and others did not identify problems such as an out-of-date medicine, cleaning issues and care records needing updates.
“Quality assurance processes were not fully effective as they were not always timely.” from the report
Do-not-resuscitate records
needs fixingRecords did not clearly show whether relatives or next of kin had been involved in some discussions, and some care plans differed from the formal decisions.
“It was not clear if relatives/next of kin had been involved in some discussions, and the information outlined in some care plans differed to decisions made in DNACPR documentation in people's care files.” from the report
- 01Have all care, risk and hospital records now been updated for the person's current needs, including choking risks and emotional distress?
- 02How are medicines given when needed recorded, including the reason if a dose is not given?
- 03How often are accidents, incidents, medicines and health and safety audits completed, and how are actions checked?
- 04How are do-not-resuscitate decisions reviewed and recorded, including discussions with relatives or next of kin?
- 05What evidence can you show that the improvements promised after the inspection have been completed?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 19 October 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.
What inspectors found, March 2021
Normandy House was inspected but not rated; inspectors found good infection control and enough staff, but this was not a full inspection.
This was an unannounced, targeted inspection on 9 February 2021. One inspector checked infection control and staffing after specific concerns had been received. They spoke with two staff members and the manager, and reviewed records, audits and policies.
The home was clean and regularly disinfected. Visitors had temperature checks and used personal protective equipment. Staff had enough protective equipment, used it correctly, and regular testing was in place for staff and residents. There were enough staff on shift to support people safely.
The home was inspected but not rated at this visit. The previous rating was Good, published on 13 November 2019. This inspection did not assess all five areas of care, so it does not provide a new overall rating.
Clean environment
The home was clean and tidy, with regular cleaning of frequently touched areas.
“The service was clean and tidy. Thorough cleaning took place regularly, which included touchpoint areas such as door handles.” from the report
Protective equipment
Staff had enough protective equipment and inspectors saw them using it correctly. There was also a safe area for putting it on and taking it off.
“Staff had access to sufficient supplies of PPE including masks, gloves, aprons and hand sanitiser.” from the report
Testing and monitoring
Regular testing and infection control checks were in place for staff and people living in the home.
“Regular testing was completed for staff and people living at the service.” from the report
Staffing levels
Inspectors found enough staff on shift and said staffing levels had been consistent at the time of inspection.
“At this inspection, we found there were enough staff on shift to safely support people, and staffing levels had been consistent.” from the report
Inspectors raised no specific concerns in this report.
- 01How have staffing levels been maintained since the inspection, including cover for staff sickness?
- 02How often are infection control audits and checks carried out now, and what happens if they identify a problem?
- 03What arrangements are currently in place for family visits and contact?
- 04What testing and protective equipment arrangements are currently in place for staff and residents?
- 05When was the last comprehensive inspection, and what were the ratings for caring, responsive and well-led?
This was a targeted inspection of infection control and staffing only; all other key questions were to be assessed at the next comprehensive inspection. This explanation was written from the published report of 9 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 Normandy House
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- October 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- November 2019Goodstayed GoodSafe: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Milton Keynes
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 90 can care for a couple. 11 years' experience on average.
“We can all fully relax around Nyarai and she feels like part of our family, which is no mean feat!”
“She was v competent and confident and we felt our mum was safe in her care. She supported us through a difficult time.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.