CQC report explained · a residential care home
What the CQC found at Norwood House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2021
Norwood House was inspected but not rated; infection control was mostly in place, but staff risk assessments and outbreak plans needed further work.
This was an announced, targeted inspection on 4 February 2021. Inspectors checked the home's infection prevention and control arrangements during the coronavirus pandemic.
Inspectors found good practice in the use of protective equipment, testing, staff training, hygiene, visiting arrangements and communication with families. They were assured about most areas they checked.
There were two areas where inspectors were only somewhat assured. Risk assessments had not been completed for some staff, and the coronavirus contingency plans did not fully cover areas such as staffing levels. The service was inspected but not rated, so this report does not provide a full quality rating.
Protective equipment
Staff followed infection control guidance and the home had enough protective equipment. Stock levels were checked by the registered manager.
“Staff followed government guidance in relation to personal protective equipment (PPE) and infection prevention and control (IPC).” from the report
Testing and training
People living in the home and staff received regular Covid-19 testing. Staff had completed infection prevention and control training.
“All staff and people living at the service received regular Covid-19 testing.” from the report
Family communication
Staff supported people's social and emotional wellbeing and kept families informed through telephone calls, video calls and other technology.
“The provider and staff kept family members up to date about the latest guidance and their relative's health via regular telephone calls and other technology including video calls.” from the report
Checks on practice
The home completed regular infection control audits and observed staff using protective equipment and carrying out hand hygiene.
“Regular Infection Prevention and Control audits had been completed to ensure the service was providing safe care and staff were following guidance.” from the report
Staff risk assessments
needs fixingRisk assessments had been completed for people but not for staff. This included some staff with medical conditions that increased the risks linked to Covid-19.
“Covid risk assessments were in place for people but these had not been completed for staff, some of which had medical conditions that increased the risks associated with Covid-19.” from the report
Outbreak planning
needs fixingThe home's contingency plans for managing Covid-19 did not cover all areas, including staffing levels. Inspectors signposted the provider to resources to improve its approach.
“Contingency plans were in place in relation to Covid management but these could be further develop to consider all areas, such as staffing levels.” from the report
- 01Have risk assessments now been completed for every staff member, especially those with medical conditions that increase Covid-19 risks?
- 02How would the home maintain safe staffing levels if there were an infection outbreak?
- 03What changes have been made to the Covid-19 contingency plans since the inspection?
- 04How often are infection prevention and control audits completed, and can families see the results?
- 05How would the home keep relatives informed if visiting was restricted during an outbreak?
This was a targeted inspection of infection prevention and control, under the Safe question only; it was not a full inspection and the service was not rated. This explanation was written from the published report of 26 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.
What inspectors found, October 2020
Rated Good; inspectors found safer care, better records and stronger management, although some staff training and incident analysis still needed attention.
This was an announced, focused inspection on 3 September 2020. One inspector spoke with two people and four staff, and checked care records, staff files, medicines, equipment, accidents and management records.
The home was rated Good overall and was rated Good for Safe, Effective and Well-led. Inspectors found that risks, medicines, staffing, infection control, food and staff support had improved. People said they felt safe, and staff responded to their needs.
The home had previously been rated Requires Improvement, with a breach of Regulation 17 about governance and records. Inspectors found enough improvement had been made, so the home was no longer in breach.
This inspection did not cover Caring or Responsive. Those ratings from the previous comprehensive inspection were used in the overall rating.
Risks were managed
Risk assessments contained enough information for staff to support people safely and were updated when needs changed. Equipment checks were also completed.
“Risks to people were well managed. Risk assessments contained sufficient information to enable staff to safely manage risks.” from the report
Medicines were safer
Medicines were stored, recorded and given safely. Staff had regular medicines training and competency checks.
“Medicines were now stored, recorded and administered safely.” from the report
Good infection control
The home was clean and tidy, and staff followed COVID-19 guidance during the inspection.
“The registered manager and staff team had implemented government guidance in relation to COVID-19.” from the report
Improved staff support
The home had introduced an induction, regular supervision and more complete training plans. A training manager had also been appointed.
“A training manager was now employed, and thorough plans were in place to address this.” from the report
Stronger management checks
Regular audits were being used to identify concerns and improvements. The manager had better oversight of the home.
“The quality assurance processes in place had improved. Audits were completed on a regular basis and were effective in highlighting concerns and areas for improvement.” from the report
Accidents were not fully analysed
needs fixingAccidents and incidents were recorded, but the home was not yet proactively looking for trends. A new system was being introduced.
“However, there was not a proactive approach to analysing data to look for trends.” from the report
Some safeguarding training was out of date
needs fixingStaff understood safeguarding, but not all staff had current training. The home planned to complete training by the end of October 2020.
“Staff had good a good understanding of safeguarding, although not all had up to date training in this area.” from the report
Some refresher training was still planned
minorCOVID-19 had affected training delivery. Refresher training on the Mental Capacity Act was planned rather than already completed for all staff.
“Staff had relevant knowledge; they knew the process to follow if they suspected a person lacked mental capacity. Refresher training was planned for all staff” from the report
- 01How will you make sure all staff have up-to-date safeguarding training?
- 02What new system are you using to analyse accidents and incidents for trends?
- 03Has the planned refresher training on the Mental Capacity Act been completed for all staff?
- 04What evidence can you show us about the Caring and Responsive areas, which were not covered by this inspection?
- 05Has the secure outdoor space been completed, and how can residents use it?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 2 October 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.
Every inspection of Norwood House
5 rated inspections over 5 years: the service has held its Good rating throughout.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2018Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- September 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 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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