CQC report explained · a residential care home
What the CQC found at Normanshire Care Services Ltd
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines systems, detailed risk assessments and effective infection prevention arrangements.
- Effective?
- Good
- People's needs were fully assessed before they moved in, and care plans covered their health, communication and sensory needs. Staff had relevant training and people were supported with food, healthcare and personal goals.
- Caring?
- Good
- This key question was not assessed during this focused inspection, so the report gives no new rating for Caring.
- Responsive?
- Good
- This key question was not assessed during this focused inspection, so the report gives no new rating for Responsive.
- Well-led?
- Good
- Management was visible and approachable. The home used audits, meetings and feedback from relatives, staff and outside professionals to monitor and improve the service.
What inspectors found, April 2023
Rated Good; inspectors found safe, effective and well-led care, with some staff skills and record-keeping still developing.
This was a focused inspection after concerns were received about people's general care and safety. One inspector visited on 20 January, 26 January and 9 February 2023. The inspector spoke with a person, relatives and staff, observed care, and checked care records, medicines, recruitment files and management audits.
The home was rated Good for Safe, Effective and Well-led. Inspectors found enough staff, safe medicines management, detailed risk assessments, suitable infection control and safe recruitment. People had personalised care plans, support with food and health, and staff training.
The rating for Effective improved from Requires Improvement at the previous inspection. The provider had acted on the earlier recommendation about assessing people's needs. Caring and Responsive were not assessed during this focused inspection, so the report does not give new ratings for those questions.
Personalised support
Care plans reflected people's individual needs, health, communication and aspirations. Staff supported people to work towards personal goals, including employment.
“People had care and support plans that were personalised, holistic, strengths-based and reflected their needs and aspirations, included physical and mental health needs.” from the report
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs, including for activities needing one or two staff. Recruitment checks were completed before staff started.
“Records confirmed, and we observed there were enough staff on duty to meet people's needs including where they needed 1 or 2 staff support for indoor and outdoor activities.” from the report
Safe medicines
Medicine records had no gaps in the sample checked. Medicines were stored correctly, and staff had clear guidance for medicines given when needed.
“We checked the medicines for three people using the service. Medicine administration records were completed correctly with no gaps.” from the report
Open management
Relatives and staff described managers as approachable. The home collected feedback and worked with healthcare and other professionals.
“Management was visible in the service, approachable and worked directly with people, leading by example.” from the report
Some communication skills still developing
minorA relative said newer staff needed more time to develop their Makaton skills. This may be important for people who rely on signs and symbols to communicate.
“A relative told us, there had been new staff starting who they felt needed time to develop skills in using Makaton.” from the report
Record-keeping gaps
needs fixingThe provider's audit identified gaps in some food and fluid charts, body check logs and waking night logs. The report says action had been taken, but families should ask how this is kept under review.
“Areas for improvement had been noted for report writing which included gaps in food and fluid charts, body check section of logs and waking night logs.” from the report
Noise at times
minorOne relative felt there could be too many staff and that the home could become noisy. Ask how the home manages noise for people who may find it distressing.
“I think there are too many staff. It can be a bit too noisy at times.” from the report
- 01How do you make sure newer staff develop the Makaton skills needed by people living here?
- 02What checks now confirm that food and fluid charts, body check logs and waking night logs are complete?
- 03How do you respond if noise levels become uncomfortable or distressing for someone?
- 04How will you keep us involved in decisions about our relative's care and risk assessments?
- 05What evidence can you show us about progress towards each person's goals?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the overall rating used the previous ratings for areas not inspected. This explanation was written from the published report of 18 April 2023 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 2022
Normanshire Care Services Ltd was inspected but not rated; inspectors found good visiting arrangements but concerns about PPE use and cleaning standards.
This was an announced, targeted inspection on 4 February 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements, and whether COVID-19 staffing pressures affected care.
The home had made arrangements for safe visits, including using an outbuilding to reduce disruption. People were also supported to take part in activities safely despite national restrictions.
Inspectors were assured about testing, admissions, shielding, social distancing, infection outbreak arrangements, and the infection control policy. However, staff did not always wear face coverings correctly, and some areas needed action so they could be cleaned hygienically.
The service was inspected but not rated. This report does not give an overall quality rating or a rated judgement for the five key questions.
Safe visiting
The home used space creatively to support family visits while reducing disruption to other residents.
“They had made creative use of space to ensure that people could continue to receive visitors without causing disruption to other people living in the home.” from the report
Activities continued
People were supported to continue activities they chose, even when national restrictions made this more difficult.
“People had been supported to continue to engage with activities of their choosing in a safe way even when national restrictions made this more challenging.” from the report
Infection control arrangements
Inspectors were assured about several infection control arrangements, including testing, safe admissions and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
COVID-19 vaccination checks
The service was meeting the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19.
“The service was meeting the requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.” from the report
PPE was not always worn correctly
needs fixingInspectors saw staff who did not always wear face coverings over both their noses and mouths. The management team said it would address this.
“We saw staff did not always wear face coverings over their noses and mouths.” from the report
Some areas needed cleaning action
needs fixingThe home needed to take action so that all areas could be cleaned hygienically.
“The provider needed to take action to ensure all areas of the home could be cleaned hygienically.” from the report
- 01What action did you take after inspectors found that staff did not always wear face coverings over their noses and mouths?
- 02How do you now check that every area of the home can be cleaned hygienically?
- 03Have the maintenance issues identified at the inspection all been completed?
- 04How are family visits arranged now, and is the outbuilding still used to reduce disruption?
- 05How do you manage staffing pressures linked to COVID-19, and what effect do they have on residents' care?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it was not a full rated inspection. This explanation was written from the published report of 23 February 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.
Every inspection of Normanshire Care Services Ltd
5 rated inspections over 7 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Normanshire Care Services Ltd →
- February 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Normanshire Care Services Ltd →
- September 2021GoodSafe: GoodEffective: Requires improvementWell-led: Good
- January 2021Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- November 2019Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Registered with the Care Quality Commission on 16 July 2014.
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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