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.
- Safe?
- Requires improvement
- Some risks were not fully identified or recorded. Inspectors also found gaps in repositioning records and unclear records of medicines returned or disposed of.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Requires improvement
- Records did not always reflect people's needs and care provided. Quality monitoring was in place, but actions identified through audits were not always recorded or revisited.
What inspectors found, October 2023
Norwood House rated Requires Improvement; inspectors found kind care and enough staff, but gaps in risk records, medicines records and quality monitoring.
This was an unannounced focused inspection on 13 September 2023. Inspectors looked at Safe and Well-led because of concerns about governance, medicines, staffing and risk management. They spoke with people, relatives, staff and a visiting professional, and checked care records, medicines records, staff files and the building.
The home had enough staff, safe recruitment and safeguarding training. People were treated with dignity, had access to healthcare and received support with diet and infection control. Staff and people described a generally positive and supportive atmosphere.
However, some risks were not fully recorded. Inspectors found gaps in records showing when one person was repositioned, and limited evidence that the home learned from incidents. Medicines disposal and return records were unclear. Food, fluid and repositioning records did not always match people's care plans, and audit actions were not always followed up.
Safe and Well-led were both rated Requires Improvement. The overall rating changed from Good at the previous inspection to Requires Improvement. The other three key questions were not inspected during this visit, so their previous ratings were carried forward.
Enough staff
The manager adjusted staffing according to people's numbers and needs. Inspectors found staff were safely recruited and there were enough staff to keep people safe.
“The service had enough staff to keep people safe.” from the report
Safeguarding
Staff had safeguarding training and understood how to identify and report concerns. Required referrals were made to the local authority and followed up.
“Staff were trained to safeguard adults from abuse.” from the report
Respectful care
Inspectors saw staff respecting people's privacy and dignity. People were generally happy with the support they received.
“We observed interactions between people and staff that were positive.” from the report
Supportive atmosphere
The home was described as welcoming, warm and supportive. Staff morale was good and the culture was open and relaxed.
“Norwood House was welcoming, and the atmosphere was warm and supportive.” from the report
Incomplete risk records
seriousNot all risks linked to people's care needs were recorded. One person's repositioning records had gaps, creating a risk that the required support was not given often enough.
“A person's care plan identified them as requiring support to change their position in bed to reduce the risk of pressure areas developing.” from the report
Medicines disposal records
needs fixingThe home had medicines policies, but there were no clear records showing medicines that had been returned or disposed of.
“However, there were no clear records available of medicines disposed of and returned.” from the report
Care records did not always match needs
needs fixingFood, fluid and repositioning charts did not always show the requirements set out in people's care plans. Inspectors asked the provider to improve its recording system.
“Records did not always evidence important information about people using the service.” from the report
Audit actions not followed through
needs fixingThe home carried out audits, but actions identified through them were not always recorded or revisited. This limited assurance that improvements were completed.
“Where improvements to the service had been identified through quality auditing, action was not always recorded.” from the report
Some areas needed refurbishment
minorInspectors were only somewhat assured about infection prevention because some areas needed refurbishment to allow more effective cleaning.
“Some areas of the care home required refurbishment to enable more effective cleaning.” from the report
- 01What has been done to make sure every person's risks are fully recorded and kept up to date?
- 02How do you now check and record repositioning support where this is part of a person's care plan?
- 03How are medicines that are returned or disposed of recorded, and who checks these records?
- 04How do you make sure food, fluid and repositioning charts match each person's care plan?
- 05Which actions from quality audits were outstanding, and how have you checked that they are now complete?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control under Safe; the other ratings carried over from the previous inspection. This explanation was written from the published report of 11 October 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
Norwood House was rated Good; inspectors found safe, effective and well-led care, with enough staff and good quality checks.
The inspection was unannounced and took place on 10 May 2022. One inspector spoke with two people, seven staff members and one visiting professional. They reviewed care records, medicines records, staff recruitment files and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found enough staff, safe recruitment, appropriate risk assessments and safe medicines management. Staff were trained and their skills were checked.
People's needs and choices were assessed and reflected in care plans. People and relatives were involved in care, and staff worked with healthcare professionals when needed. The provider used audits, feedback and incident reviews to improve the service.
The overall rating was unchanged from the previous inspection, which was also Good and was published on 6 December 2019.
Enough staff
Inspectors found staffing levels were suitable for people's needs. Staff also said there were enough people on shift.
“Appropriate staffing levels were in place to meet the needs of people in the service.” from the report
Quality monitoring
The provider used checks, audits, feedback and incident reviews to identify and address problems.
“There was an effective quality monitoring system, which ensured checks and audits were carried out, people's views were obtained and listened to and shortfalls were addressed.” from the report
Involvement in care
People and relatives were involved in care planning. Care was arranged around people's choices and preferred routines.
“People and their relatives were involved in the service. Care was planned around people's choices and preferred routines.” from the report
Staff training
New and existing staff received training, supervision and competency checks to support them in their roles.
“Regular supervisions and annual appraisals, alongside observations and competency checks helped management monitor and make sure staff had the skills and experience necessary to provide effective care.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you make sure staffing levels are sufficient for my relative's specific needs and routines?
- 02How will you involve my relative and our family in creating and reviewing the care plan?
- 03How do you check that staff remain competent to give medicines safely?
- 04How will you support my relative's particular dietary, hydration and healthcare needs?
- 05How can we give feedback or raise a concern, and how will we be told what action was taken?
The inspection report gives ratings for Safe, Effective and Well-led; it does not give separate ratings for Caring or Responsive. This explanation was written from the published report of 17 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 Norwood House
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2022Goodstayed GoodSafe: GoodWell-led: Good
- December 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- June 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015
Registered with the Care Quality Commission on 28 September 2015.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
32 live-in carers within about an hour of North Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 29 can care for a couple. 11 years' experience on average.
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.