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 requires improvement. At this assessment the rating has remained 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 provider was in breach of legal regulation in relation to people’s safe care and treatment, medicines management and governance. This included continued breaches where improvements identified at the previous inspection had not been fully embedded.
 

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 did not always have a proactive and positive culture of safety based on openness and learning. Lessons were not consistently embedded to prevent the recurrence of identified risks.

Although the provider had acted since the previous inspection, concerns remained around environmental maintenance, infection prevention and control, and medicines management, showing risks were not consistently identified or addressed through effective systems. Ongoing issues included a persistent odour in a bedroom, unresolved maintenance and cleanliness concerns, and concerns with medicines oversight such as missing guidance for staff to follow when people had ‘when required’ medicines. While the provider responded promptly during the assessment, these actions were reactive and showed that systems had not been effective in identifying and addressing risks before they affected people.

Staff and people described a culture where concerns could be raised and lessons learnt. One staff member told us, “There’s lessons learnt… management are a good sounding board to ensure the right response.” While this demonstrated openness and positive intent, the lack of sustained improvement in key risk areas showed that learning was not always used effectively to drive continuous improvement and reduce risks to people.

The provider did not always work effectively with others to establish and maintain safe systems of care. People’s safety was not always fully supported when moving between services.

Information required to support safe transitions was not always complete or accurate. Where care plans contained relevant important information, this was not always transferred effectively into summary documents used during transitions. For example, auto generated hospital passports did not include key information about people’s needs, including reference to learning disability and recent seizure activity. This placed people at risk of receiving care that was not fully informed when accessing external healthcare services. This meant external professionals may not have access to critical information to support safe and personalised care.

The provider recognised this shortfall and implemented interim measures, including printing care plans to share information while system improvements were explored. However, this demonstrated that systems were not consistently effective in ensuring safe transitions.

The provider worked with people and partners to understand safety and protect people from harm.

Systems were in place to safeguard people from abuse and avoidable harm. Safeguarding processes were understood by staff, and records demonstrated appropriate action had been taken when concerns were identified, including liaison with external professionals.

Staff demonstrated knowledge of safeguarding and how to report concerns. Records showed that incidents were reviewed, and actions taken to reduce risk, including referrals to health professionals and monitoring of known risks such as skin integrity.

People told us they felt safe and supported by staff. Safeguarding documentation and oversight processes, including monitoring of incidents and outcomes, supported a safe environment for people.

The provider did not always work effectively with people to understand and manage risks.

Care plans included risk assessments and guidance; however, these were not always fully developed or consistently focused on enabling people to achieve positive outcomes. For example, care plans included reference to individual goals such as community activities, but these were not clearly developed into workable actionable plans, limiting how risks associated with accessing the community were positively managed.

Some care planning areas lacked clarity or were incomplete, including future planning sections and aspects of end-of-life planning. This reduced opportunities to fully involve people in managing risks associated with changes in their health or wellbeing.

While staff demonstrated an understanding of people’s needs in practice, this was not always reflected consistently in written records, meaning risks were not always clearly documented or proactively managed.

The provider did not always detect and control risks in the care environment.

Although improvements had been made, environmental risks remained. We identified a range of maintenance and cleanliness issues, including worn furnishings, damaged fixtures, and areas requiring repair or decoration. A shower room was out of use due to a leak, limiting access to facilities.

One bedroom presented with a strong and persistent odour, and cleaning measures had not been effective in addressing this. This indicated that environmental risks were not always effectively managed.

Records showed maintenance checks were undertaken; however, issues identified had not always been resolved in a timely way. While the provider had engaged a maintenance contractor and actions were in progress, the presence of ongoing concerns demonstrated that systems were not consistently effective in maintaining a safe environment.

The provider had sufficient staff who were supported to provide safe care.

There were enough staff deployed to meet people’s needs, and staff files demonstrated safe recruitment practices, including appropriate checks prior to employment. Staff received regular supervision, probation reviews, and competency assessments.

Staff told us they felt supported in their roles and had access to training and development opportunities. Systems were in place to monitor staff performance and provide oversight of practice.

The provider had introduced a new training system to improve access and understanding, including support for staff whose first language was not English. This supported staff to develop the skills required to meet people’s needs safely.

The provider did not always assess or manage the risk of infection effectively.

Infection prevention and control practices were not consistently effective. We identified areas requiring improved cleanliness, including bedding, equipmentand bathroom facilities.

Cleaning schedules and checks were in place; however, these had not always ensured consistent hygiene standards. This increased the risk of the spread of infection.

The provider acted during the inspection to address concerns, including deep cleaning and changes to the environment. However, these actions were reactive and highlighted that systems were not consistently effective in maintaining infection control standards.

The provider did not always ensure medicines were managed safely.

We identified gaps in medicines management, including unclear labelling of some topical medicines and incomplete guidance for a ‘when required’ (PRN) medicine. Records did not always include sufficient detail to support safe administration, such as required timing for specific medicines.

Recording errors were also identified, including incorrect date for prescribed medicines. These issues had not been identified through routine systems, increasing the risk of unsafe administration.

The provider acted promptly to address concerns, including implementing PRN protocols and correcting records. However, these issues demonstrated that medicines systems were not consistently effective in ensuring safe practice.