CQC report explained · a residential care home
What the CQC found at Normanton Retirement Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found blocked fire exits, a wedged-open fire door, an incorrectly fitted stair gate, exposed hot water systems and unsafe or poorly maintained equipment. Infection control was not effective, although medicines, staffing and safeguarding were generally good.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff supported people with healthcare, food and drink, consent, choice and least restrictive care.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff spent time with people, supported independence and involved them in decisions about their care.
- Responsive?
- Good
- Care plans included people's preferences and what mattered to them. People had activities, help with communication, support to maintain relationships and access to complaint procedures.
- Well-led?
- Requires improvement
- The provider's quality checks did not identify important safety and cleanliness problems. The management team had not completed key risk assessments or regular environmental checks.
What inspectors found, March 2020
Normanton Retirement Home was rated Requires Improvement; inspectors found kind care but serious problems with safety, infection control and quality checks.
This was an unannounced inspection on 17 February 2020. One inspector and one assistant inspector spoke with people living in the home, relatives, a visitor and staff. They also observed care and checked care, medicine, recruitment and management records.
The home was rated Good for Effective, Caring and Responsive care. People were supported by kind staff, involved in decisions, helped to access healthcare and offered personalised care and activities.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found blocked fire exits, unsafe fire doors, unsuitable equipment, poor cleanliness and no evidence of a legionella risk assessment. Quality checks had failed to identify these problems.
The overall rating fell from Good at the previous inspection, published on 3 October 2017. The provider told inspectors about some actions taken after the visit, but these changes had not been independently checked.
Kind and respectful care
People described staff as kind and respectful. Inspectors saw positive interactions and staff supported people without taking away their independence.
“Throughout this inspection we saw positive interactions between people and staff.” from the report
Personalised support
People and those close to them were involved in care planning. Plans recorded personal preferences, what mattered to people and their life histories.
“These plans included people's personal preferences, things that mattered to them, what they liked and what they didn't like.” from the report
Good support with choice and healthcare
People were asked for permission, supported to make choices and helped to access healthcare professionals when needed.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests.” from the report
Safe medicines support
Staff were trained and assessed as competent before helping people with medicines. Guidance was available for medicines given when needed.
“People received safe support with their medicines.” from the report
Fire and building safety
seriousFire exits were blocked and a fire door was wedged open. Other hazards included an unsafe stair gate, exposed hot water systems and a broken bath hand grip.
“These issues put people at risk of harm.” from the report
Infection control and cleanliness
seriousInspectors found extensive dirt, staining, rust and a mould-like substance in parts of the home. There was also no evidence of a legionella risk assessment or preventative checks.
“The infection prevention and control processes at Normanton Retirement Home were ineffective.” from the report
Weak quality monitoring
seriousThe provider's checks had not found the problems with safety, cleanliness and equipment. Environmental and infection control checks were not carried out often enough.
“The provider had ineffective systems in place to monitor the quality of the service they provided.” from the report
Medicine storage incident
needs fixingPrescribed creams were left in a communal toilet where people could access them. The manager removed and stored them correctly when inspectors raised this.
“However, we did see a box containing prescribed creams had been left in a communal toilet where people had access to them.” from the report
- 01Have all fire exits been kept clear, and have the fire doors and fire risk assessment been reviewed?
- 02Has the specialist legionella risk assessment been completed, and how are hot water safety checks recorded now?
- 03What work has been completed to deal with the rust, staining, mould-like substance and other cleanliness problems?
- 04How often are the building, equipment and infection control now checked, and who reviews the results?
- 05What has changed since the inspection, and can we see evidence that the changes have been independently checked?
This was an unannounced inspection covering all five CQC questions, including the premises and care provided; the previous overall rating was Good in 2017. This explanation was written from the published report of 12 March 2020 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, October 2017
Rated Good; inspectors found safe, kind and personalised care, with the home remaining Good since its previous inspection.
This was an unannounced comprehensive inspection on 26 July 2017. The inspector and an expert by experience spoke with people living at the home, relatives, staff and the registered manager. They also reviewed care, medicines and management records, and observed care.
Inspectors found that people were protected from harm, had their medicines safely managed and had enough staff available. Staff were trained and supported, and people's health needs, choices and changing needs were monitored.
The care was described as kind, respectful and individual. Families were welcomed, activities reflected people's interests, and people could raise concerns. All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home was also rated Good at the June 2015 inspection.
People felt safe
People said staff were available when needed. Inspectors found that risks were assessed and managed, and that medicines were stored and given safely.
“People continued to receive support which protected them from harm and abuse.” from the report
Kind and respectful care
Staff spoke gently, listened to people and supported them at their own pace. Inspectors saw a strong focus on dignity, individuality and emotional wellbeing.
“The care people received was very kind, caring and compassionate.” from the report
Good family involvement
Families were welcomed and encouraged to stay involved in visits, meals, celebrations and activities. The report also says staff supported relatives during end-of-life care.
“Relationships with families and friends were cherished and well established.” from the report
Personalised activities
People could choose whether to join activities, and staff adapted activities when people could no longer go out. Examples included a pub-style bar, church visits and school children reading to people.
“People were supported and encouraged to engage in a variety of activities and some people still regularly enjoyed spending time independently out in the local community.” from the report
Open management
People and staff said they could speak openly with the manager. The home used audits and other checks to identify and address issues.
“There were a number of systems in place to identify and rectify any issues with the quality of the service when they arose.” from the report
Inspectors raised no specific concerns in this report.
- 01How are medicines checked now, and how is staff competency confirmed before staff administer them?
- 02How often are my relative's care plan and risks reviewed, and how will I be told if their needs change?
- 03What activities are available for someone with my relative's interests, abilities or health needs?
- 04How will my relative and our family raise a concern or complaint, and how will it be followed up?
- 05How are audits of medicines, infection control, maintenance and care records carried out now?
This was an unannounced comprehensive inspection covering all five areas: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 3 October 2017 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 Retirement Home
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 21 December 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.
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