CQC report explained · a residential care home
What the CQC found at Normanton Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2022
Normanton Lodge Care Home is rated Requires Improvement; inspectors found safe medicines and kind care, but weaknesses in financial safeguards, risk checks and oversight.
This was an unannounced focused inspection on 8 March 2022. One inspector spoke with four people, 11 staff and seven relatives. The inspection looked at Safe, Effective and Well-led, including infection control measures.
The home managed medicines safely, followed people's care preferences and supported people with food, healthcare and decision-making. Staff were safely recruited and there were enough staff on the rotas.
However, the systems for managing people's money were not robust. Some risks were not identified or properly managed, and accidents in the Glen Care Village were not included in the home's analysis. The CQC found breaches of regulations about safeguarding from abuse and good governance.
The overall rating changed from Good to Requires Improvement. The home must send an action plan, and the CQC will monitor progress. The report says no evidence was found that people had been harmed, but the weaknesses left people at risk.
Medicines
Medicines were administered by trained staff, according to prescribing instructions. Stock checks, records and guidance for as-needed medicines were in place.
“Medicines were safely managed. Regular checks were completed of the medication stock and records” from the report
Personalised care
Care plans recorded people's choices and preferences and were reviewed as needs changed. Staff knew people's dietary requirements and followed them.
“Care plans included detailed individual information about people's choices and preferences” from the report
Staffing and recruitment
The home followed safe recruitment checks and rotas showed enough staff were deployed. People were supported by familiar staff.
“Staff were recruited safely. The service followed safe recruitment processes to ensure people were suitable for their roles.” from the report
Support and relationships
Inspectors saw staff talking and listening to people and supporting activities. Relatives described staff as knowing people well and involving them in care planning.
“There was a person-centred and positive approach to the planning, delivery and reviewing of people's care” from the report
Food and healthcare
People were supported to eat and drink with dignity and patience. The home worked with healthcare professionals and included their guidance in care plans.
“Where people needed support to eat and drink we observed this to be provided with dignity and patience.” from the report
Financial safeguards
seriousThe home's procedure for managing people's money had not been followed. The CQC said this left people at risk of financial abuse.
“The providers procedure for managing people's finances had not been followed by staff, and required improvement, this left people at risk of financial abuse.” from the report
Risk assessments
needs fixingSome risks had not been identified or properly reduced. Inspectors found one person was at risk when using their kitchen independently, although the manager sent a risk assessment after this was raised.
“Systems and processes in place to review care records had not identified all risks” from the report
Accident oversight
seriousThe system for analysing accidents did not include incidents from the Glen Care Village. Some falls had not been actioned by the manager or included in accident analysis.
“We found a number of incidents where people had suffered a fall these incidents had not been actioned by the registered manager or included in their accident analysis.” from the report
Quality checks
needs fixingThe home carried out regular audits, but those audits had not found the problems with finances, risk assessments and accident analysis.
“However, these audits had not identified the concerns we found with financial procedures, gaps in risk assessments and poor analysis of accidents and incidents.” from the report
- 01What has changed to make sure every financial transaction follows the home's procedure and is checked?
- 02How are risks such as using a kitchen independently now assessed, recorded and reviewed?
- 03How are accidents and falls in the Glen Care Village recorded, investigated and included in management analysis?
- 04What actions were included in the required improvement plan, and which have now been completed?
- 05How will managers check that their audits identify problems with financial safeguards, risk assessments and accident reviews?
This was a focused inspection of Safe, Effective and Well-led, including infection control; Caring and Responsive were not inspected in this visit, and ratings for uninspected questions were carried over from the previous inspection. This explanation was written from the published report of 22 April 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, February 2021
Normanton Lodge Care Home was inspected but not rated; infection-control arrangements were in place, but risk assessments, PPE storage and cleaning records needed improvement.
This was an unannounced, targeted inspection on 18 December 2020. It looked only at infection prevention and control during the coronavirus outbreak.
Inspectors were assured that people and staff were tested regularly, new admissions were handled safely, and government visitor guidance was followed. The infection-control policy was up to date.
There were also important gaps. Staff removed PPE in a communal area, PPE was not always stored safely, COVID-19 risk assessments were missing, and cleaning records were incomplete. The home made environmental improvements after the inspection.
The service was inspected but not rated. This means the report does not give an overall Good, Requires improvement or Inadequate rating.
Regular testing
People and staff were being tested regularly for COVID-19. Positive results were followed by appropriate isolation arrangements.
“Processes were in place for testing people and staff regularly for COVID-19.” from the report
Safe admissions
The home was following guidance when admitting people.
“People were being admitted safely into the service with guidance being followed.” from the report
Up-to-date policy
The infection-control policy contained guidance for staff to follow.
“The providers infection prevention and control policy was up to date and contained appropriate guidance for staff to follow.” from the report
Visitor controls
Inspectors were assured that the home was following government guidance to reduce the risk of visitors spreading infection.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Missing individual risk assessments
seriousThere were no risk assessments for people or staff who might contract COVID-19. This meant individual safety risks had not been considered when planning care.
“No risk assessments were in place for people or staff in relation to contracting COVID-19.” from the report
PPE was not always handled safely
seriousStaff were seen removing PPE in a communal area. Spare masks were not easy to access and PPE was left in places where it could become contaminated.
“In several areas around the home, PPE was left in places where they could become contaminated.” from the report
Cleaning records were incomplete
needs fixingDaily cleaning schedules were not always signed. There were also not enough antibacterial wipes and no records showing that required touch-point cleaning had taken place.
“These were not always signed to show cleaning had been completed.” from the report
Untidy communal areas
seriousSome equipment and household items were stored in areas used by people. Inspectors said this increased the risk of cross infection and made cleaning difficult.
“This increased the risk of cross infection and made cleaning difficult.” from the report
- 01How are individual COVID-19 infection risks for people and staff assessed and recorded now?
- 02Where is PPE stored, and how do you make sure it is not contaminated or removed in communal areas?
- 03How do you check and record cleaning of touch points every two hours?
- 04What environmental improvements were made after the inspection, and have they all been maintained?
- 05How do you make sure moving and handling equipment is labelled for the correct person?
This was an unannounced targeted inspection of infection prevention and control only, and the service was inspected but not rated. This explanation was written from the published report of 9 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 Normanton Lodge Care Home
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- April 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- May 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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