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Inspection Summary

Overall summary & rating


Updated 11 May 2016

This inspection took place on the 24 March 2016 and was unannounced.

At our last comprehensive inspection of 29 October 2013 we found the service was meeting the requirements of the regulations in place at the time.

Normanhurst Residential Home (Normanhurst) is registered to provide care for up to twenty three older people, some of whom may live with dementia. Seventeen people were being cared for at the time of our visit.

The service did not have a registered manager currently in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. Following the resignation of the previously registered manager a recruitment process had recently been completed and an appointment made. After the inspection visit we confirmed the registration application process for the new manager was underway.

The majority of the feedback we received was very positive about the service. “Thank you for the wonderful care you have provided for our mother” and “care is first rate” were some of the comments made to us by people who lived in Normanhurst or their relatives. There was some concern expressed about inconsistent record keeping and the pressure at times on staff which were said to have led to people being; “rushed” when being assisted to get up in the morning. We have made a recommendation about this in the report.

There were safeguarding procedures in place and staff received training on safeguarding vulnerable people. This meant staff had the skills and knowledge to recognise and respond to safeguarding concerns.

Risks to people were identified and managed well at the service so that people could be as independent as possible. A range of detailed risk assessments were in place to reduce the likelihood of injury or harm to people during the provision of their care.

We found set staffing levels were adequate to meet people’s needs effectively. The staff team worked well together and were committed to ensure people were kept safe and their needs were met appropriately. The senior management team gave additional support when required due to short-notice absences of regular staff.

Staff had been subject to a robust recruitment process. This made sure people were supported by staff that were suitable to work with them.

Staff received appropriate support through induction and supervision. Although formal supervision was only approximately two to three monthly, all the staff we spoke with said they felt able to speak with the senior management team or senior staff at any time they needed to. There were also team meetings held to discuss issues and to support staff.

We looked at records of training for all staff. We found there was an on-going training programme to ensure staff gained and maintained the skills they required to ensure safe ways of working.

Care plans were in place to document people's needs and their preferences for how they wished to be supported. These were subject to review to take account of changes in people's needs over time. We found some inconsistency in the level of detail and completeness of care records. We have made a recommendation about this in the report.

Medicines were administered in line with safe practice. Staff who assisted people with their medicines received appropriate training to enable them to do so safely.

The service was managed effectively. In the absence of a registered manager the senior management team regularly checked quality of care at the service through audits and by giving people the opportunity to comment on the service they received and/or observed.

Inspection areas



Updated 11 May 2016

The service was safe.

There were sufficient staff available, with support from the senior management team, to meet people’s assessed care needs.

Risks to people had been appropriately assessed as part of the care planning process and staff had been provided with clear guidance on the management of identified risk.

People were supported with their medicines in a safe way by staff that had been appropriately trained.



Updated 11 May 2016

The service was effective.

People received safe and effective care. Staff were supported to achieve this through structured induction, regular supervision and training.

People were encouraged to make decisions about their care and how it was provided. Decisions made on behalf of people who lacked capacity were made in their best interests.

People received the healthcare support they needed to maintain their health and well-being.



Updated 11 May 2016

The service was caring.

Staff treated people with dignity and respect and protected their privacy.

People were supported by staff who engaged positively with them whilst they provided care and support.

Staff knew people well and understood people’s different needs and the ways they liked their support provided.



Updated 11 May 2016

The service was responsive.

There was a detailed care planning process which helped staff provide people’s care in the way they wanted them to.

The service responded appropriately when people’s needs changed. This ensured their needs continued to be met and that they could remain as independent as possible.

People were supported, when they wanted to take part in activities and social events in order to provide stimulation and entertainment.


Requires improvement

Updated 11 May 2016

Although the providers and staff worked well together as a team the service was not being consistently well-led as the level of detail in and completeness of records was inconsistent.

Staff, relatives and people who used the service were able to talk with the providers and senior staff when they needed information, advice or support.

There were adequate quality assurance systems in place to both monitor the quality of care provided and drive improvements within the service.