CQC report explained · a residential care home
What the CQC found at Norwood House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and staff understood how to manage risks and report abuse. Inspectors found improved risk assessments, safer surroundings and well-organised medicines systems, although some staff raised concerns about staffing pressure.
- Effective?
- Good
- People's needs were assessed and staff had received improved training. Inspectors found that consent was usually respected, but supported decision-making was not always consistent or clearly recorded.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people's preferences and inspectors observed positive relationships between staff and residents.
- Responsive?
- Good
- Care plans included people's likes, dislikes and preferences. People were supported to maintain relationships and take part in activities, including dementia-friendly group and one-to-one activities.
- Well-led?
- Requires improvement
- Management and oversight had improved, but audits did not always show what was being checked or whether improvements were lasting. Some staff also described a less open culture and felt under pressure.
What inspectors found, May 2023
Rated Good overall; inspectors found safe, kind and responsive care, but leadership and quality checks still require improvement.
This was an unannounced comprehensive inspection on 20 April 2023. Inspectors observed care, reviewed six care plans, medicines records, recruitment files and management records. They also spoke with people, relatives, staff and healthcare professionals.
The home was rated Good for Safe, Effective, Caring and Responsive. People were generally safe, treated kindly, supported with their medicines and helped to take part in activities. Care plans had improved and were more personalised.
Well-led was rated Requires Improvement. The home had introduced better audits and electronic care records, but these systems were not yet being used consistently to show lasting improvement. Inspectors also found that supported decision-making was not always clear and some staff reported pressure and a less open culture.
The previous inspection, published on 30 December 2022, rated the service Requires Improvement overall and found breaches of regulation. At this inspection, improvements meant the home was no longer in breach of regulations. CQC will continue to monitor the service.
People felt safe
People and relatives said they felt safe. Staff understood safeguarding and knew how to respond to risks.
“People and their relatives told us they felt safe living at Norwood House.” from the report
Kind and respectful care
Inspectors saw staff speaking politely and respecting people's privacy, dignity and choices.
“People were cared for by staff who were kind and compassionate.” from the report
Improved care records
The electronic care planning system made records more up to date and personalised. It also helped staff monitor wellbeing, meals and medicines.
“Care records had been transferred to an electronic care planning system.” from the report
Activities and relationships
People were supported to see visitors and join activities suited to their interests and needs.
“People were involved in the planning of the activity programme, which includes exercise groups, arts and crafts, visiting entertainers, therapy dogs, spending time in the garden and baking.” from the report
Quality checks not yet reliable
needs fixingAudits had improved but some records described policies rather than checking whether care was effective. Inspectors wanted to see evidence of sustained improvement.
“However, we had concerns that the purpose of audits was not fully understood as some audit records referred to there being a policy in place rather than looking at the subject of the audit.” from the report
Staffing pressure
needs fixingRelatives were satisfied with staffing, but some care staff said there were not enough staff and that care could be rushed. The provider said it would explore these concerns.
“Sadly as hard as the carers work, because of the more "organisational" impact, corners have to be cut, care is often rushed and person-centred care is becoming a thing of the past.” from the report
Decision-making records
needs fixingStaff understood the Mental Capacity Act, but records did not always clearly show how people were supported to make their own decisions.
“Supported decision making was not consistent and it was not always clear how people were supported to make their own decisions.” from the report
Some staff felt less open
minorMost staff felt supported, but some said they felt watched by CCTV and criticised in supervision meetings. Management engagement needed to continue improving.
“However, some staff described a less open culture.” from the report
- 01What specific changes are being made to ensure audits check the quality of care and show sustained improvement?
- 02How do you make sure there are enough staff on each shift, especially when staff say care can be rushed?
- 03How will my relative be supported to make decisions, and how will this be recorded in their care plan?
- 04How are staff supported to raise concerns openly about staffing, CCTV and supervision?
- 05How are medicines audits recorded in enough detail to show what was checked each month?
This was an unannounced comprehensive follow-up inspection covering all five key questions, after the previous inspection found legal breaches. This explanation was written from the published report of 18 May 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, December 2022
Rated Requires Improvement, with Well-led rated Inadequate; inspectors found risks, poor management and inconsistent support that need urgent improvement.
Inspectors visited on 2 and 9 November 2022. The first visit was unannounced. They observed care, reviewed five care plans, medicines records, staff recruitment files and records about accidents, safeguarding and how the home was managed. They spoke with people, relatives, staff and other professionals.
The home was not always safe or effective. Risk assessments and care plans did not always match the care being given. Emergency evacuation records were out of date, some areas of the building were unsafe, and staff training was not always current. Mealtimes were poorly organised and records of food and fluids were incomplete.
The home was rated Inadequate for being well-led. Systems for checking quality and making improvements had not worked. There had been several managers in a short period, and repeated action plans had not led to lasting improvement. The home was already rated Requires Improvement at its previous inspection.
There were some positive findings. Medicines were generally stored and given safely, staff recruitment checks had been completed, infection control arrangements gave inspectors assurance, and people said they felt safe. The provider was told to make improvements, received a warning notice for governance, and will be monitored.
Medicines
Inspectors found medicines were stored safely and observed staff administering them safely. There were still some recording discrepancies, so this was not a completely problem-free area.
“Medicines were stored safely, including those that required refrigeration.” from the report
Recruitment checks
The required checks had been completed before the staff files reviewed began work at the home.
“All required checks had been completed before staff began working at the service.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infections, including its use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Professional relationships
Feedback from a visiting professional was positive about the relationship with the home and staff's knowledge of people.
“We received feedback from a professional who stated they were happy with their relationship with the home, that they felt the staff knew people well” from the report
Risks were not managed reliably
seriousCare plans recorded safety actions that were not always carried out. Inspectors also found unsafe access to stairs, possible ligature points and an inaccurate emergency evacuation list.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service This placed people at risk of harm.” from the report
Consent and best interests
seriousStaff were not properly supported to respond safely and respectfully when people refused personal care. Care records did not explain how this should be done.
“Where somebody did not consent to care, staff were not supported to understand what action they should take.” from the report
Poor leadership and oversight
seriousThe provider's checks had not identified or corrected repeated problems. There had also been a high turnover of managers, and this area was rated Inadequate.
“Systems had not been established to effectively manage and improve the service.” from the report
Mealtimes and nutrition records
needs fixingSome people waited more than 30 minutes for meals, while staff supported several people at once. Food and fluid records did not clearly show what people had eaten or what extra support was given.
“Staff were observed to be supporting more than one person with their meal.” from the report
Visiting arrangements were unclear
needs fixingRelatives gave different accounts of visiting and found it difficult to make appointments. The provider said it would review the arrangements and improve communication.
“Relatives spoken with were unclear about visiting procedures.” from the report
- 01What has the home done to make sure risk assessment actions, such as repositioning and supervision near stairs, are carried out and recorded?
- 02How are you keeping the emergency evacuation list accurate for everyone living here?
- 03What training and supervision have staff now completed on dementia care, safeguarding and the Mental Capacity Act?
- 04How do you make sure people receive timely, individual support at mealtimes and that food and fluid records are complete?
- 05Who is currently responsible for managing the home, and how are you checking that the warning notice and action plan have been addressed?
This inspection rated Safe, Effective and Well-led; Caring and Responsive were not rated, and the Safe and Effective ratings carried over as Requires Improvement from the previous inspection. This explanation was written from the published report of 30 December 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 Norwood House
9 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- December 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2016Requires improvementstayed Requires improvementWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- October 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 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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