Norwood House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the management and safety of the premises and equipment

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff told us they were supported to speak up and were confident that any associated investigations would be completed in an open and transparent way. Any resulting actions were used to support learning, improve practices and prevent future harm. Processes were in place to identify trends, with concerns flagged for monitoring to keep people safe. For example, from incidents like falls and medication errors. People and their relatives told us they felt safe and were supported to manage known risks. One person said, “It’s safe here. No problems. Staff are always popping in to see if you are alright.”

Incomplete records meant people could receive care that was not fully informed or personalised when moving between services. For example, documents did not always show the needs of people with a learning disability or include plans to manage behaviours linked to mental health conditions.

This created a risk that care and support during transitions might not be safe or tailored to individual needs. The registered manager responded to our feedback and provided assurances that care plans would be reviewed and updated. Staff told us people’s needs were generally understood. However, this was not always reflected in written records.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, they did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Systems intended to keep people safe were not always effective. For example, the service had not acted to manage a person’s behaviour. As a result, incidents occurred where other people using the service and staff were subjected to verbal abuse. This showed that risk management plans and safeguarding processes were not consistently implemented or reviewed to prevent harm. The lack of timely action increased the risk of unsafe care and avoidable harm.

The provider did not always work well with people to understand and manage risks. Electronic care planning systems were in place and used to monitor people’s care and support. However, care plans and risk assessments did not always contain detailed guidance for staff to follow when people became distressed. We saw staff attempting to provide reassurance to a person who had become verbally aggressive. Their response was not immediately effective, and the incident visibly impacted the wellbeing of other residents and staff. Additionally, staff had not received robust training in managing behaviour associated with distress, which limited their ability to respond effectively and safely.

People were exposed to avoidable risks because systems to maintain a safe environment were not consistently applied. While immediate action was taken after feedback, the lack of proactive monitoring and timely maintenance meant the environment was not always safe. The provider did not always detect and control potential risks in the care environment. Equipment, facilities, and technology were not consistently maintained to support the delivery of safe care. Processes and daily checks intended to maintain a clean and safe home environment were not always effective. We saw rusty radiator covers, damaged furniture and carpets, and overdue Portable Appliance Testing (PAT), which had not always been identified or acted on. These shortfalls increased the risk of harm from unsafe equipment and compromised the overall safety of the environment. The registered manager acted following our feedback by scheduling PAT testing, deep cleaning, and arranging replacement equipment.

There were enough safely recruited and suitably inducted staff on duty, and both people and staff told us there were enough staff to keep people safe and meet their needs. However, improvements were needed to ensure staff had the necessary skills and knowledge to provide safe and effective care. For example, staff had not received robust training in supporting people with a learning disability, or in implementing Positive Behaviour Support (PBS) strategies. This limited their ability to respond confidently and consistently to people’s behaviour, increasing the risk of unsafe or ineffective care. After our feedback, the provider advised they were changing their training provider and planned to update staff skills and competencies.

People were at increased risk of infection because cleaning and hygiene systems were not consistently effective. The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Although some corrective action was taken following feedback, the lack of regular infection control practices compromised safety. Cleaning processes and monitoring systems were not sufficient to maintain hygiene standards. We observed unclean areas, including bedding, mattresses, bathrooms, toilets, laundry facilities, and extractor fans, which posed a risk of cross-contamination. These failures indicated that infection prevention measures were not consistently applied. After feedback, the provider improved cleaning and maintenance control routines to reduce infection risks.

People were confident their medicines were handled safely and in a way that respected their choices. Staff worked with people to promote the safe and effective use of medicines. The provider ensured that medicines and treatments were managed safely and in line with people’s needs, capacities, and preferences. Staff involved people in decisions about their medicines and supported them to understand any changes. Medicines were stored securely, administered as prescribed, and records were accurate and complete. Systems were in place to monitor medicine use, and respond to any issues, ensuring people received their medicines safely. A relative said, “The staff do [person’s name] medication and if they’re in pain they will give them some pain relief.”