Normanton Lodge Care Home

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 assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. The service was no longer in breach of regulation relating to governance.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us they understood what changes leaders had made and felt things had improved. One staff member told us, “I feel confident in where we are going.” Staff were involved in meetings with leaders and invited to share their ideas and their opinions on whether any changes had been successful in improving the service. People contributed their views through meetings with staff and actions were taken in response to people’s feedback.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and staff spoke highly of the leadership team. One staff member told us, “I can go to [Registered Manager] they are always ready to listen and are really receptive; they listen, and things improve.” Feedback from the most recent survey sent to relatives, showed they felt they had positive relationships with staff and were updated on any care changes.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff understood their duty to report any concerns and told us they felt confident to do so. One staff member told us, “I’ve spoken up several times and there is no backlash.” Another staff member told us they would always advocate for people to ensure they received the care they needed. People felt confident in speaking with staff if they had any worries and told us they felt listened to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff were treated fairly. Team meetings fostered a supportive culture amongst staff members. For example, leaders took action to help ensure working patterns were equitable and helped support staff to complete their required training.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Systems and processes to monitor, reduce risks and improve the service were effectively operated. Leaders had oversight of all accidents, incidents and near misses, including falls. Trends were identified and this informed how leaders planned staff deployment to help prevent falls in specific areas of the home.

However, records did not always meet expected standards. Leaders had identified some improvements were required to records and record management systems. This included how digital systems were used to capture full details of people’s care and the accuracy of care plans and risk assessments. Whilst action plans and reviews of records were underway to work towards improvements in this area, these had not resolved all the issues at the time of our inspection and further work was required to ensure records met expected standards.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People received joined-up care. Staff supported a person to be ready on time for visiting healthcare professionals to accompany them to an external health appointment. Staff told us they would prepare information on people’s care needs ready to go with them should they need to go to hospital. This helped ensure people received the care they needed.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Leaders took opportunities to reflect and learn from events and this approach had been embedded in the culture of the service. Action plans supported work towards continuous improvement across a range of areas. These actions helped to improve the quality and safety of people’s care.