CQC report explained · a residential care home
What the CQC found at Norton Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found unsafe medicines systems, gaps in risk management and weak oversight, although people spoke positively about the care.
This was an unannounced focused inspection on 14 and 16 February 2023. Inspectors reviewed Safe, Effective and Well-led, including infection control under Safe. They spoke with people, families, staff and a visiting professional, observed care and checked care, medicines, staff and management records.
The home was not always safe. Medicines were not consistently given as prescribed, some risk assessments and care plans were out of date, and equipment used to reduce health risks was not always serviced or working. The home was also not consistently following legal requirements about consent and restrictions on people’s liberty.
The overall rating is Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. Caring and Responsive were not inspected in this visit, so their previous ratings were used in the overall rating. The home remained in breach of regulations after the previous inspection.
Positive relationships
People generally spoke positively about the care and said staff knew them well and were approachable.
“In general, people spoke positively about the care they received and told us staff were approachable.” from the report
Staff availability
Inspectors found enough staff on duty during both inspection days. Recruitment checks were completed before staff started work.
“There were enough staff on duty to meet people's needs.” from the report
Food and mealtimes
Staff knew people’s dietary needs and preferences. Inspectors saw positive support at mealtimes, and people said they liked the food.
“The nutritional needs of people were being met. Staff were aware of people's dietary needs and preferences.” from the report
Working with other services
Records showed that people were supported to access GPs and other health services when needed. Staff worked with other agencies.
“Staff worked with other agencies to ensure people received consistent, effective and timely care.” from the report
Medicines
seriousStaff did not always follow instructions about when medicines should be given. Doses were sometimes too close together, some timed medicines were late or missed, and thickener was not always recorded.
“Medicines were not managed safely. Staff did not always follow prescribers' guidance when administering medicines.” from the report
Risk equipment
seriousTwo pressure-relieving mattresses were six months overdue for servicing, and one was faulty. A sensor mat intended to reduce falls risk was not being used and did not work.
“We found the routine servicing for pressure relieving mattresses for 2 people was 6 months overdue and 1 of these mattresses was showing as faulty.” from the report
Care plans and risk records
seriousSome care plans and risk assessments did not reflect people’s current needs or give enough detail. Incident records were not always complete and lessons were not analysed well.
“On a number of occasions, we found risk assessments and care plans either did not reflect peoples current care needs or lacked sufficient detail to mitigate risk.” from the report
Consent and restrictions
seriousRecords for DoLS authorisations were inaccurate or out of date. One authorisation had expired and had not been reapplied for in time.
“We found the DoLS authorisation for 1 person had expired and had not been reapplied for in the required timeframes.” from the report
Management checks
needs fixingAudits and daily checks did not identify several problems, or did not lead to prompt improvement. Staff meetings and supervisions had also not taken place in recent months.
“Audits and daily checks to monitor standards and to identify where improvements could be made were not always effective.” from the report
Environment
minorSome communal corridors and bathing facilities needed redecoration to maintain safe and hygienic standards.
“Areas of the service needed refurbishment to ensure safe and hygienic standards were maintained.” from the report
- 01What changes have been made to ensure all medicines are given at the correct time and in line with prescribers’ instructions?
- 02How often are pressure-relieving mattresses and other risk-reduction equipment serviced, and how do you check that they are working?
- 03How are care plans and risk assessments updated after falls, safeguarding concerns or other incidents?
- 04How do you track DoLS applications, renewals and conditions so that authorisations do not expire?
- 05What evidence can you show that the warning notices and the required action plan have been addressed?
This was an unannounced focused inspection of Safe, Effective and Well-led, with infection prevention and control checked under Safe; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 13 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, June 2022
Norton Lodge rated Requires Improvement; inspectors found unsafe medicines and risk management, while leadership was improving.
The inspection took place on 17 and 29 March 2022. It began as a targeted check of infection prevention and control during the coronavirus pandemic, but was widened to include Safe and Well-led after concerns about the environment and risk management. The inspector spoke with people, relatives and staff, and checked care plans, medicines records, recruitment files and management records.
Inspectors found that medicines were not always given as prescribed. Some risk assessments and records were incomplete, including risks linked to choking, falls and smoking. They also found defective fire doors and a cluttered fire escape. These issues placed people at risk, although inspectors found no evidence that anyone had been harmed.
Staffing, recruitment, safeguarding and infection control were positive. Relatives said visiting was safe and unrestricted. The home had a new registered manager and had started making improvements, but audits had not found the problems inspectors identified and the new systems needed time to become established.
The overall rating changed from Good at the previous inspection in 2018 to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The provider was asked to send an action plan, and CQC said it would monitor progress.
Staffing
Inspectors found enough staff to meet people's needs. Recruitment checks were carried out safely.
“There were enough staff to meet people's needs. Staff were deployed effectively to ensure that people's needs were met in a timely way.” from the report
Infection control
Staff used protective equipment and followed good infection control practices. Relatives described visiting arrangements as safe.
“Staff followed good infection control practices and used PPE (personal protective equipment) to help prevent the spread of healthcare related infections.” from the report
Safeguarding
Staff had safeguarding training and understood how to recognise and report abuse. People and relatives said they felt the care was safe.
“Staff had received training in safeguarding. Staff understood how to recognise, report and safeguard people from abuse.” from the report
Improving leadership
A new registered manager and deputy manager had begun introducing systems to track training, legal authorisations and care planning. Professionals said the home had improved in recent months.
“The home has improved significantly over the last few months with more continuity for the residents.” from the report
Medicines
seriousSome people did not always receive medicines at the correct time. Instructions for giving medicines when needed were not always available.
“People did not always receive their medicines as prescribed. For example, one person who required medicines at a certain time to manage a health condition did not always receive these at the correct time.” from the report
Risk records and fire safety
seriousSome risk assessments were missing or had not been updated after incidents. Inspectors also found defective fire doors, a cluttered fire escape and unassessed risks linked to smoking.
“We found concerns with defective fire doors, a cluttered fire escape and risks relating to people smoking had not been assessed.” from the report
Quality checks
needs fixingThe home's audits had not identified the problems found during the inspection. The provider needed to improve its checking systems.
“Issues we found at this inspection with fire safety, risk assessments and medicines management had not been identified.” from the report
Cleaning records
minorThe environment was clean and staff used good infection control practices, but records did not show that frequently touched surfaces were cleaned regularly in line with guidance.
“Cleaning records did not show that high touch points were cleaned regularly in line with best practice guidance.” from the report
- 01What immediate action was taken to ensure medicines are given at the prescribed times and that as-needed medicines have clear instructions?
- 02Have all people's choking, falls and other risk assessments been completed and reviewed after incidents?
- 03Have the defective fire doors and cluttered fire escape been put right, and have smoking-related risks been assessed?
- 04How do you now check that medicines, risk assessments and fire safety systems are working properly?
- 05What progress has been made in embedding the new care planning, training and legal-authorisation systems?
This began as a targeted infection prevention and control inspection but became a focused inspection of Safe and Well-led; the other ratings carried over from the previous inspection. This explanation was written from the published report of 9 June 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 Norton Lodge
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodWell-led: Good
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016
Registered with the Care Quality Commission on 19 January 2016.
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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