Norwood House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessmentthe rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to governance at the service. This was a continued breach, as systems had not consistently ensured sustainable improvements following the previous inspection.

This service scored 57 (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 have a consistently embedded culture that ensured high-quality, person-centred care.

The registered manager described how they supported people to make informed decisions and involve external professionals and families where appropriate. While there was a stated commitment to providing person-centred care, this was not consistently reflected across all aspects of the service. Care planning systems, monitoring processes and environmental management did not always support this vision in practice.

Although improvements had been made following the previous inspection, these were not always sustained. For example, continued issues in care planning, environmental standards and oversight demonstrated that the provider’s approach was not fully embedded within daily practice.

This meant the culture was not consistently effective in ensuring safe, high-quality care.

Leaders did not always demonstrate the capacity to consistently drive and sustain improvements.

Leaders were visible within the service and responded to issues raised during the inspection. However, improvements were often reactive rather than proactively identified through effective governance systems.

Although leaders recognised areas requiring improvement and had plans in place, these had not always been implemented in a timely or sustained way. Ongoing concerns across multiple areas, including care planning, environmental maintenance and monitoring systems, indicated that leadership oversight was not consistently effective.

This meant leaders were not always able to ensure the consistent delivery of high-quality care.

The provider promoted a culture where people and staff felt able to raise concerns.

There was evidence of an open culture within the service, where staff and people were able to raise concerns. Systems such as meetings and informal discussions supported communication between staff and management.

Care approaches demonstrated that people’s day-to-day needs were responded to, and staff were able to seek support and guidance when required.

Although systems to gather feedback were in place, these were not always consistently used to drive sustained improvement across the service.

The provider supported an inclusive workforce and promoted equality within the service.

The provider had taken steps to support staff from diverse backgrounds, including implementing training systems that were accessible in different languages and formats. This supported staff engagement and understanding.

Staff were supported through supervision, training and development opportunities, contributing to a working environment where staff could carry out their roles effectively.

These approaches demonstrated a commitment to equality and inclusion within the workforce.

The provider did not always operate effective governance systems to assess, monitor and improve the quality and safety of the service.

Governance systems were in place but were not consistently effective in identifying and addressing risks. Issues identified at the previous inspection, including concerns relating to care planning, environmental standards and oversight, had not been fully resolved or sustainably improved.

Monitoring systems, including audits and checks, had not consistently identified areas of risk. For example, gaps in care planning, incomplete documentation, and continued environmental concerns had not been effectively addressed through routine governance processes.

The provider had acted in response to feedback during the assessment; however, these actions were reactive. This demonstrated that governance systems were not consistently effective in ensuring continuous improvement or preventing recurrence of issues.

In addition, the provider had not always ensured that care delivery was fully aligned with registration requirements and current best practice guidance for the needs of people using the service.

The provider did not always work effectively in partnership with others to improve outcomes for people.

While staff engaged with external professionals such as healthcare services, systems to ensure effective partnership working were not always fully embedded. Information sharing between services was not consistently effective, particularly in supporting transitions and continuity of care. Documentation did not always support a fully coordinated approach, which reduced opportunities to ensure joined-up care and improved outcomes for people.

The provider did not always demonstrate a consistent focus on learning and improvement.

Although the provider had taken steps to improve the service, these were not always sustained or embedded into practice. Learning from previous concerns had not consistently resulted in effective, long-term improvements.

Systems to identify trends, learn from issues, and implement improvements were not consistently effective. Changes were often made in response to inspection findings rather than through proactive monitoring. The provider described improvements to training systems and staff support; however, these had not yet consistently translated into sustained improvements in practice. This meant opportunities to drive continuous improvement and innovation were not fully realised.