CQC report explained · a residential care home
What the CQC found at South Norwood Hill
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind, personalised care, but medicines records and checks were not reliable enough.
This was an unannounced inspection on 05 July 2022. One inspector spoke with two people, the director, the registered manager and one care worker. They reviewed care records, medicines records, staff training and management records.
The home supported four people with mental health conditions and could accommodate up to five people. Inspectors found enough staff, suitable risk assessments, good support with health, food and daily living, and kind relationships between people and staff.
The main problem was medicines recording. The home could not always match medicine stocks with records to confirm people had received medicines as prescribed. The quality checks had not identified or fixed this problem.
The overall rating was Requires Improvement. Effective, caring and responsive care were rated Good. Safe and well-led were rated Requires Improvement. The rating had improved in some areas since the last inspection, but the overall rating remained Requires Improvement.
Enough staff
Inspectors found enough staff to support people safely. Staff were not working excessive hours and said they did not feel rushed.
“There were enough staff to care for people safely and they told us they did not feel rushed.” from the report
Kind relationships
People said staff understood them and listened to them. Inspectors saw people who appeared comfortable with staff.
“Staff are nice, kind. They understand me, they always listen” from the report
Personalised care
Care plans reflected people's mental health needs, backgrounds, personalities and preferences. Staff followed these plans.
“Care plans were personalised and kept up to date so they remained reliable for staff to follow.” from the report
Improvements since the last inspection
The provider had improved staffing arrangements, premises safety and infection control. The responsive rating improved from Requires Improvement to Good.
“The quality and safety of the service had improved for people overall since our last inspection.” from the report
Medicine records
seriousMedicine stocks carried over between months were not always clearly recorded. Staff also did not always record whether one or two tablets had been given when there was a choice.
“These issues meant the provider could not always check stocks against medicine administration records to confirm people received their medicines as prescribed.” from the report
Quality checks missed the problem
needs fixingThe home's audits were generally effective, but they did not identify or resolve the medicines management concerns found during this inspection.
“checks of medicines management required improvement as they had not identified or resolved the concerns we found.” from the report
- 01How are you using the new medicine balance sheet to check medicine stocks against administration records?
- 02How do you record medicines taken away when people are on social leave, and how do you check that they have taken them correctly?
- 03How do you now check whether staff have recorded the correct number of tablets when there is a choice?
- 04What actions are included in your improvement plan, and how will you show that the medicines problems have been fixed?
- 05How will you keep families informed about progress with the issues identified in this inspection?
This was an inspection of the care home and its premises across all five CQC questions; the rehabilitation support provided in people's own homes was outside the inspection remit. This explanation was written from the published report of 28 September 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.
What inspectors found, April 2020
Rated Requires Improvement; inspectors found kind, personalised care but important safety and management weaknesses.
This was the first inspection since the home registered. It was unannounced and took place on 6 February 2020. Inspectors spoke with three people, the manager, a director and a support worker. They reviewed care records, medicines records, staff files, audits and other management records.
The home was rated Good for Effective, Caring and Responsive. People were treated with respect, involved in their care and supported to maintain their health and independence. Staff knew people well, and care plans were personalised.
The home was rated Requires Improvement for Safe and Well-led. Staff had sometimes been scheduled to work 48 waking hours in a row. Health and safety checks, infection control arrangements, food hygiene registration and management audits were not good enough. The provider agreed to make several changes after the inspection.
Kind and respectful support
People generally liked the staff and were treated with dignity. Staff were calm, patient and understood people's mental health needs.
“We observed staff spoke kindly and respectfully to people and were calm and patient when a person began to express aggressive thoughts.” from the report
Personalised care
Care plans included people's backgrounds, personalities and preferences. People were involved in decisions about their care through keyworkers and reviews.
“People's care plans detailed their mental health needs, their backgrounds, personalities, those who were important to them and how they preferred to receive their care.” from the report
Medicines managed safely
Inspectors found that medicines were received, stored, given and disposed of safely. Records and stock checks showed people received medicines as prescribed.
“Our checks of medicines stocks and records showed people received their medicines as prescribed.” from the report
Support for health and independence
People were supported to access healthcare and develop daily living skills such as cooking, cleaning and laundry.
“Staff supported people to learn independent living skills such as cooking, cleaning and laundry so they could live independently in the future, where possible.” from the report
Excessive staff working hours
seriousSome staff were scheduled to work 48 waking hours in a row. The provider agreed to stop this immediately, but inspectors said tiredness could affect safe care.
“On the rotas several staff were scheduled to work 48 waking hours in a row.” from the report
Incomplete safety checks
seriousThe home had not completed all checks for window restrictors, water temperatures, water hygiene and a garden trip hazard. Some fixes were confirmed after the inspection.
“The provider had not carried out all the necessary health and safety checks for a care home.” from the report
Infection control and food hygiene
seriousThe washing machine was unsuitable for contaminated laundry and was in the kitchen. The home had also not registered for the national food hygiene rating scheme. The provider said these issues were addressed after the inspection.
“The provider had not ensured the washing machine could wash contaminated clothing and bedding at sufficiently high temperatures in the year since the service opened.” from the report
Weak management oversight
needs fixingThe provider's audits did not identify or resolve the problems inspectors found. Inspectors also identified gaps in the manager's knowledge of care home management.
“These checks had not identified and resolved the issues we found including those relating to unsafe staff working hours, health and safety, food hygiene and infection control.” from the report
Some records needed improvement
needs fixingRecords of challenging behaviour were inconsistent. Some care plans also needed more detail about oral hygiene, diabetic care and one person's support needs.
“However, the service lacked a standard format to record the details which meant the records lacked consistency.” from the report
- 01Have staff stopped working 48 waking hours in a row, and how do you check that rotas remain safe?
- 02Have window restrictors, water temperature checks, water hygiene assessments and the garden trip hazard all been dealt with?
- 03Is contaminated laundry now washed safely and kept away from food preparation areas?
- 04Have you registered with the local authority food hygiene rating scheme?
- 05How are audits now checking that safety, infection control and care-record problems are found and corrected?
This was an unannounced first inspection of the care home, covering all five CQC questions; rehabilitation support provided in people's own homes was outside the inspection scope. This explanation was written from the published report of 1 April 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 South Norwood Hill
2 rated inspections over 2 years: the service has held its Requires improvement rating throughout.
- September 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2020Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2019
Registered with the Care Quality Commission on 6 February 2019.
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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At least 100 live-in carers within about an hour of Croydon
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Most charge £980 to £1,230 a week. 77 can care for a couple. 11 years' experience on average.
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