CQC report explained · a nursing home
What the CQC found at Norwood House Nursing 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
- Some health and safety risks were not assessed or monitored robustly. Pressure-relieving mattresses were not always set correctly, and accident and incident records were inconsistent. Medicines, staffing, safeguarding and infection control were found to be safe.
- Effective?
- Requires improvement
- The home did not always follow the Mental Capacity Act. Capacity assessments and best-interest decisions were not always clear or in place when restrictions were used. Staff training, nutrition and links with health professionals were positive.
- Caring?
- Good
- No rating is given in this report. People and relatives described staff as kind, caring and attentive, and inspectors observed a warm and supportive approach.
- Responsive?
- Good
- No rating is given in this report. Inspectors found person-centred care, activities, outings and an environment adapted for people living with dementia.
- Well-led?
- Requires improvement
- Quality checks did not always identify problems in care records, accidents and risk management. There was also a positive and open culture, with approachable managers and staff who felt supported.
What inspectors found, January 2024
Rated Requires Improvement; inspectors found kind care and safe medicines, but important risks, consent records and quality checks were not always managed safely.
Inspectors visited on 6 and 14 December 2023. The first visit was announced and the second was unannounced. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was praised for kind and attentive care, safe medicines, enough staff, good infection control and links with health professionals. People’s nutritional needs were met, and the building and gardens were well maintained.
However, some risks were not assessed or monitored properly. Pressure-relieving mattresses were not always set correctly, records about complex behaviours were incomplete, and accidents and incidents were not recorded consistently. The home also did not always follow the rules about mental capacity and best-interest decisions.
The overall rating changed from Good at the previous inspection in 2018 to Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. The report says the provider took immediate action on some issues, but CQC will monitor whether improvements are made.
Kind and attentive care
People and relatives spoke positively about the standard of care. Inspectors saw a warm, inclusive atmosphere and staff who understood people’s needs.
“People and relatives praised the standard of care and said staff were kind, caring and attentive.” from the report
Medicines managed safely
Medicine systems and records were well organised. The home also improved the instructions for medicines given only when needed during the inspection.
“Medications systems were organised and records well completed.” from the report
Staffing and training
Inspectors found safe staffing levels, suitable recruitment procedures and staff with appropriate training and support.
“The service made sure staff had the skills, knowledge and experience to deliver safe care and support.” from the report
Health support and activities
The home worked closely with health and social care professionals. People had access to exercise, activities outside the home and outings.
“There were close links with other health and social care professionals, including weekly meetings with the GP.” from the report
Dementia-friendly environment
The home was described as spacious and homely. It had pictorial signs, different-coloured bedroom doors and outdoor areas designed to support people living with dementia.
“People living with dementia were supported with pictorial signage and menus.” from the report
Risks were not always controlled
seriousSome people’s risks were not assessed or monitored safely. Four people who needed pressure-relieving mattresses had mattresses set incorrectly, increasing the risk of harm.
“We reviewed 4 people who had been assessed to need pressure relieving mattresses and the settings were not set correctly.” from the report
Consent and best-interest records
seriousThe home did not always follow the Mental Capacity Act. Best-interest assessments were missing or not robust when restrictions such as bed rails and sensors were used.
“Where people lacked capacity and restrictions such as bed rails and sensors were in place best interest assessments had not always been carried out.” from the report
Quality checks missed problems
seriousAudits did not always identify shortfalls in care records, accident forms and risk management. Staff also recorded events in different places, making records harder to check.
“The provider's systems did not always effectively monitor the service to drive improvements in service delivery.” from the report
Incomplete behaviour records
needs fixingSome risk assessments for people who became upset or agitated were not person-centred or fully completed. This could lead to inconsistent support.
“Where people presented with complex behaviours which resulted in them becoming upset and agitated risk assessments were not person-centred and records were not always fully completed.” from the report
- 01What checks have you completed to make sure pressure-relieving mattresses are set correctly for every person who needs one?
- 02How do you record capacity assessments and best-interest decisions when bed rails, sensors or other restrictions are used?
- 03How are accidents, incidents and risks now recorded so managers have a complete and accurate overview?
- 04What changes have you made to care plan audits, and can you show how they have found and fixed previous shortfalls?
- 05How do staff record and respond to complex behaviours so support is consistent and person-centred?
This inspection rated Safe, Effective and Well-led; no ratings were given for Caring or Responsive, and the report says ratings for key questions not inspected carry over from the previous inspection. This explanation was written from the published report of 20 January 2024 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 2018
Norwood House Nursing Home was rated Good overall; inspectors found kind, safe care but needed improvements in management and records.
Inspectors visited without notice on 4 September 2018. They observed care, looked around the building, checked records and spoke with people, relatives and staff.
People were generally safe and received kind, respectful care. Staffing levels, recruitment checks, medicines management, healthcare support and care planning were all judged good. People also had suitable food choices and access to drinks and snacks.
The home was rated Requires Improvement for being well-led. The new manager had not started the CQC registration process. Some complaint and safeguarding records were incomplete, some care plans needed updating, and quality checks needed further development.
The overall rating stayed Good, the same as at the previous inspection. The report says all fundamental standards were being met.
Safe staffing
Inspectors found enough staff to support people safely and keep the home clean. Recruitment checks were completed before new staff started.
“There were enough staff on duty to care for people safely and keep the home clean.” from the report
Safe medicines
Medicines were stored and managed safely. Records and stock checks gave inspectors assurance that people received medicines as prescribed.
“Medicines were managed safely. Clear records were kept of medicine administration which provided assurance people were receiving their medicines as prescribed.” from the report
Kind and respectful care
Staff supported people's dignity, personal presentation, choices and communication needs. Relatives were positive about the care.
“People using the service and their relatives were positive about the care and support provided at Norwood House.” from the report
Individual care
People's needs were assessed before admission and care plans included detailed information about their support and preferences. Staff knew the people they cared for.
“People's care plans contained detailed information about the care and support they needed together with their personal preferences.” from the report
Healthcare support
People were seen by appropriate healthcare professionals, including GPs, specialist nurses and speech and language therapists.
“People's healthcare needs were being met.” from the report
Manager registration
needs fixingA new manager was in post but had not started the process of registering with CQC. This contributed to the Requires Improvement rating for well-led.
“A manager was in place but they had not yet applied for registration with the commission.” from the report
Incomplete records
needs fixingRecords of complaints and safeguarding events were not kept in a way that allowed the home to review patterns. Some care plans also needed updating after weight loss.
“Some documentation surrounding the management of complaints and safeguarding needed improving.” from the report
CQC notifications
needs fixingSafeguarding alerts had been managed appropriately, but the home had not informed CQC about them as required.
“We found safeguarding alerts had been made by the service and although these had been managed appropriately, CQC had not been informed.” from the report
Quality monitoring
needs fixingAudits and reports were being used, but the quality assurance systems needed further development to make sure they were effective.
“Quality assurance systems were in place to assess, monitor and improve the quality of the service. These needed to develop further to ensure they were effective.” from the report
Activities
minorA basic range of activities was available, but some people said they wanted more. An activities co-ordinator was due to start.
“People provided mixed feedback about activities with some saying they wished there were a few more activities in the home.” from the report
- 01Has the manager now applied for registration with CQC, and what support and oversight are in place while this is completed?
- 02How are complaints and safeguarding events now recorded, reviewed and reported to CQC?
- 03How do you make sure care plans are updated promptly when someone loses weight or their needs change?
- 04Are staff supervisions and appraisals now up to date?
- 05What activities are currently available, and has the activities co-ordinator started?
This was an unannounced inspection that reviewed all five CQC questions, including care, safety, the premises, records and how the home was managed. This explanation was written from the published report of 11 October 2018 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 Norwood House Nursing Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 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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