CQC report explained · a nursing home
What the CQC found at Normanhurst Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, staffing, recruitment, medicines and infection control were generally managed safely.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. Inspectors did observe kind interactions, and people said they were happy with their care.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify missing or incomplete records. The service improvement plan also lacked clear actions, timescales and named responsibility.
What inspectors found, October 2021
Rated Good overall; inspectors found safe, kind care, but leadership and quality checks required improvement.
Inspectors made an unannounced visit on 23 September 2021. They spoke with people living at the home, staff, relatives and health professionals. They observed care and checked care plans, medicines records, staff files and management records.
People said they felt safe and were happy with their care. Inspectors found enough staff, safe medicines management, good infection control measures and a clean home. Staff were seen speaking kindly to people and spending time with them.
The main weakness was leadership and quality checking. Audits had not found some missing records, including cleaning checks, medicine trolley temperature checks and records about medicine hidden in food or drink. The provider acted on these issues after the inspection, but the improvement plan was not detailed enough.
The overall rating remained Good, as it was at the previous inspection. Safe was rated Good. Well-led fell from Good to Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used for the overall rating.
People felt safe
People and relatives told inspectors that people were safe at the home. Staff understood how to recognise and report abuse.
“People told us they felt safe at the home.” from the report
Safe medicines
Medicines were ordered, stored, given and disposed of through established systems. Staff giving medicines had competency checks.
“Medicines were managed safely. There were systems in place to ensure medicines were ordered, stored, given and disposed of safely.” from the report
Kind, personal care
People said they were happy with how staff treated them. Inspectors saw staff spending time with people and supporting their individual interests.
“Staff were not rushed and spent time talking and laughing with people.” from the report
Clean and infection-controlled
The home was very clean and inspectors found effective measures for visiting, testing, personal protective equipment and managing infection outbreaks.
“The home was very clean and tidy, however staff told us they did not record areas they had cleaned.” from the report
Quality checks missed problems
needs fixingThe provider's audits did not identify several recording problems. This did not affect people during the inspection, but it could make it harder to find issues promptly.
“Quality assurance systems were not effective in identifying concerns.” from the report
Improvement plan lacked detail
needs fixingThe service improvement plan listed some areas for improvement but did not clearly say how they would be achieved, when they would be completed or who was responsible.
“The provider's service improvement plan was not detailed enough to be effective.” from the report
Relatives felt excluded
minorRelatives were kept informed about changes and incidents affecting their loved ones, but they did not feel involved in the home's wider running or regularly asked for their views.
“Relatives told us they had not been sent surveys or been part of any discussions about the service.” from the report
Mixed views about staff
minorRelatives praised some staff but felt some did only what was required and did not go further for people.
“They care for [person's] physical needs but don't ever go the extra mile.” from the report
Important records were missing
needs fixingRecords were not always kept for airflow mattress checks, cleaning, medicine trolley temperatures, or agreement for one person's medicine to be hidden in food or drink. These issues were acted on after the inspection.
“The medication audit had not identified that temperature checks of the medicine trolley were not being recorded.” from the report
- 01What has changed to make sure audits now find missing cleaning, mattress and medicine records?
- 02How do you record and review decisions to give medicines hidden in food or drink?
- 03Have relative meetings, surveys or other ways of gathering relatives' views now restarted?
- 04How are you managing the lack of a manager registered with CQC?
- 05What actions, timescales and responsible people are now included in the service improvement plan?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 21 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, February 2021
Inspected but not rated; inspectors found strong infection-control arrangements but some gaps in risk assessments and audits.
This was a targeted, announced inspection on 1 February 2021. It looked at infection prevention and control during the coronavirus pandemic, rather than the full quality of care.
Inspectors found a designated COVID team, regular testing, trained staff, safe use of protective equipment and good cleaning arrangements. Visitors were protected, and the home was following shielding and social distancing rules.
Inspectors were only somewhat assured that outbreaks could be prevented or managed effectively. Some staff worked elsewhere, risk assessments did not record Black, Asian and minority ethnic risks, and infection-control audits had not been completed recently.
The service was inspected but not rated. This report does not give an overall quality rating or ratings for the other four questions.
Dedicated COVID team
A named team managed testing, visitor arrangements and keeping infection-control procedures up to date.
“There was a designated 'Covid team' at the home. This staff team were responsible for the testing of staff, residents and visitors.” from the report
Testing and protective equipment
Staff and agency workers were tested before entering, and staff had training in putting on and removing protective equipment.
“Each staff member undertook a lateral flow test before each shift and were not able to enter the building without having a negative test.” from the report
Clean environment
Inspectors found the home clean and hygienic, with signs identifying busy areas and a system for leaving unused rooms before deep cleaning.
“The home was clean and hygienic. There were signs around the home which identified 'pinch points'.” from the report
Visitor safety
Inspectors were assured that visitors were being prevented from catching and spreading infections.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Staff working elsewhere
needs fixingSome staff did not work exclusively at the home. Inspectors said this created a risk of cross-contamination, although measures had been introduced to reduce it.
“Staff working in the home did not always work exclusively for the home. This was discussed with the manager and measures had been put into place to reduce the risk of cross contamination.” from the report
Incomplete risk assessments
needs fixingRisk assessments considered several COVID-19 risks but did not include risks affecting Black, Asian and minority ethnic staff.
“The risk assessments did not include Black, Asian and minority ethnic (BAME) risks but the manager had discussed this with each staff member.” from the report
Infection-control audits
needs fixingRegular infection-control audits had stopped during the pressure of the outbreak and were being reinstated.
“Due to the increased pressure from the outbreak, IPC audits had not been completed recently. The home was in the process of reinstating these but had made regular checks of the environment.” from the report
- 01Have infection-prevention and control audits now been reinstated, and what have the most recent results shown?
- 02How do you reduce cross-contamination risks when staff work for other services?
- 03Have COVID-19 risk assessments been updated to include Black, Asian and minority ethnic risks?
- 04How are agency staff block booked and tested before entering the home?
- 05What evidence can you provide that visitor testing, protective equipment and cleaning arrangements remain in place?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not assess the other four CQC questions or provide an overall rating. This explanation was written from the published report of 12 February 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 Normanhurst Nursing Home
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- October 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- December 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 31 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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