Archived: Norwood Green Care Home

Updated 11 October 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection visits took place over two days. The first day of the visit was conducted by two inspectors, a nurse specialist advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

The second visit was conducted by a member of the CQC medicines team.

Service and service type

Norwood Green Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Norwood Green Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We looked at all the information we held about the provider which included the action plan following the last inspection, information about safeguarding concerns and notifications of significant events from the provider. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

During the inspection

We spoke with 10 people who lived at the service and the visitors for three people. We met staff on duty who included nurses, care workers, senior care workers, the management team and the activities coordinator. We observed how people were being cared for and supported. Our observations included the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked at the records the provider used for managing the service, which included care records and staff records, as well as meeting minutes and audits. We looked around the building and looked at how medicines were being managed.

Updated 11 October 2022

About the service

Norwood Green is a care home with nursing for up to 92 older people. At the time of our inspection 76 people were living at the service. Some people were living with the experience of dementia and some were being cared for at the end of their lives. The service is managed by Four Seasons Healthcare, a private organisation proving care in residential care homes across England and Scotland.

People’s experience of using this service and what we found

The risks of people falling had not always been fully assessed or mitigated.

People did not always have opportunities for meaningful and engaging activities.

The provider's systems for monitoring and improving the quality of the service were implemented. But sometimes these were not effective enough to enable the required changes and improvements.

People received care and support which met their health and personal care needs. The staff worked closely with other healthcare professionals to make sure needs were assessed and planned for. People had enough to eat and drink.

People received their medicines safely and as prescribed.

There were enough staff to keep people safe and meet their needs. The staff received the training and support they required to understand how to care for people safely and well.

People were cared for by kind staff who understood people's differences and respected these. They supported people to make choices and people told us they liked the staff and had good relationships with them.

There were systems designed to safeguard people from abuse. The provider investigated and learnt from complaints, allegations of abuse, accidents and incidents. They shared learning with the staff to help improve the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 2 December 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found some improvements had been made, but the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We carried out an unannounced comprehensive inspection of this service on 9 August 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person-centred care and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Responsive and Well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has not changed and remains requires improvement. This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Norwood Green Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, person-centred care and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.