Archived: Norwood Green Care Home

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.

Norwood Green is a residential care home providing personal and nursing care to 55 people aged 65 and over at the time of the inspection. The service can support up to 92 people and is registered to provide nursing care to people with dementia, mental health needs and general nursing care.

The home accommodates people across three separate units, two that provide nursing care and one that provides personal care for those people without a nursing support need. Norwood Green is part of Four Seasons Limited, a national organisation that provides mostly care home services to people in the UK.

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

We found end of life care plans were not always detailed and did not reflect people’s preferences or the support they required to meet their diverse , spiritual, and cultural needs. There was therefore a risk that all their needs might not be met.

Some social and recreational activities were taking place in the home, but these were not always effective in stimulating and keeping people engaged. There was a lack of dementia friendly signage and points of reference to help ensure the premises were always suitable to meet the needs of all people using the service. Some people’s bedrooms were not personalised and lacked personal objects and items of interest to make their bedrooms homely and inviting.

The provider had reviewed their recruitment procedures to ensure staff had been recruited in a safe manner. Some recruitment records had been identified as missing during audits. The provider was working towards addressing this concern. Staffing levels were assessed and provided accordingly to ensure there were adequate staffing levels to meet people’s needs. People assessed as requiring one to one care received this.

The management team had systems and processes to monitor and audit the quality of the care provided. Whilst the management team had made improvements in addressing the management of risks and improving wound care to people there were still some aspects of the service which required addressing and improvement.

There had been over the past few years several changes of managers and deputy managers. Some staff told us they found these changes of management disruptive and difficult. The provider was aware of this dynamic and had tried to facilitate continuity where possible so any improvements were embedded and sustained over time.

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.

We found the systems and practices for managing the risk of pressure ulcers and management of wound care were embedded. The nursing staff were knowledgeable and supported the care workers to provide appropriate skin and pressure area care to people.

Medicines were well managed by staff who had received training and understood their responsibilities to administer medicines in a safe manner.

People and their relatives told us they felt safe in the home. They found staff to be, “good” and “friendly” with a “good atmosphere,” in the home. We found during our observations staff and management were caring and kind towards people. They spoke in calm and reassuring tones. The provider had systems in place to identify safeguarding adult concerns and to report and investigate accordingly.

People were supported to access health care professionals and services. Nursing staff were well informed, and staff had received training and support to meet people’s health support needs. People were supported to eat meals in line with their assessed nutritional needs. Most people spoke favourably about the meals served.

The provider demonstrated they supported the staff well and were open, transparent and inclusive in the way they managed the service.

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 24 September 2019). Since that inspection we undertook a targeted inspection to look at the management of pressure ulcers and wound care (published 12 August 2020) but we did not rate the inspection at that time and the rating remained as requires improvement.

At the previous rated inspection (24 September 2019) the service was in breach of Regulations 9 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We served a Warning Notice on the provider for the breach of Regulation 9 and a requirement notice for the breach of Regulation 17. 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 that the provider had made some improvements but remained in breach of the two Regulations. They told us and showed us plans to make further improvements to meet the Regulations.

Why we inspected

This focused inspection was carried out to follow up on action we told the provider to take at the previous inspections of the service.

We found evidence that the provider needs to make improvements. Please see the effective, responsive and well-led sections of this full report.

We also 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.

Enforcement

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

You can see what action we have asked the provider to take at the end of this full report.

Follow-up

We will continue to monitor information we receive about the service using our monitoring activity system. This will indicate when we next inspect the service.

Norwood Green is a residential care home providing personal and nursing care to 42 people aged 65 and over at the time of the inspection. The service can support up to 92 people and is registered to provide nursing care to people with dementia, mental health needs and general nursing care. The home accommodates people across three separate units, two that provide nursing care and one that provides personal care. Norwood Green is part of Four Seasons Limited a national organisation that provides mostly care home services to people in the UK.

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

During the inspection we found the provider had systems and processes in place to help keep people safe. We did not fully look at the way the provider managed medicines but, we found the instructions for the application of one person’s topical cream were not clear. This meant there was a risk the medicine would not be applied appropriately and consistently to the person. We also observed a medicines trolley that was closed but not locked which meant people could potentially access the medicines.

We found that some of the care plans we looked at were not person centred and therefore did not effectively meet people’s needs. This included the ineffective use of a behavioural tool for one person, and the communication care plan of another person, which lacked clear guidance about the support the person needed. The manager was aware of the need to make care plans more person centred and was in the process of reviewing and rewriting them.

We were specifically looking at the management of pressure area care and we saw evidence that the provider had taken a number of actions to improve the assessment and management of pressure ulcers. We also found the provider had appropriate infection control policies and procedures in place. Staff gave positive feedback about the current manager and changes in the service.

During the inspection we found that the provider had made improvements to the assessment and management of pressure ulcers. However, there remains significant concerns around sustainability and the provider being able to demonstrate the changes are embedded and will be maintained.

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

Rating at last inspection

The last rating for this service was requires improvement (published 4 October 2019).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns regarding the prevention and management of pressure ulcers and wound care. A decision was made for us to inspect and examine those risks. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement

At the previous inspection the service was in breach of Regulations 9 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We served a Warning Notice on the provider for the breach of Regulation 9 and a requirement notice for the breach of Regulation 17. At this inspection we found that the provider had not fully met the requirements of the Warning Notice and remained in breach of the two Regulations but was in the process of making further improvements to meet these.

We will ask the provider for an updated action plan and new timescales to confirm by when they will make all the necessary improvements in relation to the Warning Notice. Please see the back of the report for the action we are taking in relation to the breach of Regulation 17.

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. We will work alongside the provider and local authority to monitor progress. If we receive any concerning information we may inspect sooner.

Norwood Green Care Home is a nursing care home providing personal and nursing care to 73 people aged 65 and over at the time of the inspection.

The home is part of Four Seasons Limited a national organisation that provides care to people in the UK. Norwood Green Care Home is registered to provide nursing care to 92 people with dementia, mental health needs and general nursing care. The home accommodates people across three separate units, two that provide nursing care and one residential care unit. Each unit has separate adapted facilities including bathrooms, lounges and dining areas. There is a central kitchen on the ground floor and a large communal garden.

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

People and relatives told us that there were no organised activities at the home. For some people this meant they were bored and even lonely as they felt they had not had the opportunity to make new friends. The provider did not have person centred care plans. This was because plans lacked background information about people and their lives prior to living in the home.

End of life care plans contained medical information but some plans lacked people’s diversity support information. This meant religious or cultural observances that might be important to them might not take place as they would want to happen.

Medicines were administered and stored appropriately by nursing staff who were well informed. However, guidelines for ‘per required needs’ (PRN) medication was limited and not person-centred.

Some health records were not completed in line with good practice and would not provide sound evidence to support health professionals’ decision making.

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.

The provider mostly worked in line with the Mental Capacity Act 2005 (MCA). The provider had applied for Deprivation of Liberty Safeguards appropriately with one oversight. There were mental capacity assessments in place and some best interest decisions, but a couple of mental capacity decisions were not decision specific and required some more detail. We made a recommendation the provider look at good practice in implementing the MCA

The provider had audits and checks in place and had identified where for example some weekly safety checks had not taken place. However, they had not addressed the shortfalls we found during our inspection.

People spoke positively about staff. Staff were observed to be caring and interactions with people were unrushed and sensitive. People were supported to eat in an encouraging and appropriate manner. We observed staff gave people choice and promoted their independence.

The provider trained staff and valued their input and views. They had taken steps to recruit more permanent staff and nurses to offer a more consistent service to people.

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

Rating at last inspection

The last rating for this service was requires improvement (published 18 July 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection not enough improvement had been made. Whilst the provider was no longer in breach of regulation 12 Safe care and treatment and regulation 18 Staffing, they were still in breach of Regulation 17 Good governance and Regulation 9 Person centred care.

Why we inspected

This was a planned inspection based on the previous rating.

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

We have identified breaches in relation to Regulation 9 Person centred care and Regulation 17 Good Governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The last comprehensive inspection was in July 2016. The service was rated requires improvement in the key question 'Is the service Effective?’ because we found a breach of regulation regarding premises and equipment. Overall the service was rated good. A focused inspection was carried out in April 2017 when we found the provider continued to breach the regulation regarding premises and equipment and in addition was breaching the regulation in regards to person centred care. We served a requirement notice for the breach related to person centred care and a warning notice on the provider for the breach of regulation in regards to the premises asking them to make the necessary improvements. We also asked the provider to complete an action plan to show what they would do and by when to improve the rating of the key question of 'Is the service Effective?’' to at least good.

At this inspection we found the provider had made improvements and had met the regulation in regards to the premises. However, we found three additional breaches of regulations, and a repeated breach for the regulation in regards to person centred care and the service continues to be rated requires improvement

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

The home is part of Four Seasons Limited a national organisation that provides care to people in the UK. Norwood Green Care Home is registered to provide nursing care to 92 people with dementia, mental health needs and general nursing care. The home accommodates people across three separate units, each of which have separate adapted facilities. There is a central kitchen on the ground floor and a large communal garden. At the time of our inspection there were 88 people living in the home.

There was a registered manager who joined the service in November 2017 and registered with the Commission in May 2018. 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.

The provider sent us an action plan in April 2017 that stated the bathrooms would be refurbished by June 2017. We found in this inspection that all bath and shower rooms were refurbished to a good standard. We had received no action plan about addressing the concern about person centred care. We found a continuing breach of this regulation because people were still not receiving their choice of bathing or showering in accordance with their care plans.

People, relatives and visitors told us that people were not supported to get up when they wanted to, that they were not receiving showers when they wanted them and that planned activities were sometimes cancelled. They expressed that there were not enough care staff in the home. We found that the registered manager was assessing staffing need using an electronic system. However, people were not always being supported in line with their care plans and this indicated that staffing levels were not sufficient to provide a person centred service.

We found a number hazards in the service that had not been identified and addressed through checks and audits. These included an overgrown garden that was not safe for people to use as there were trip hazards. There were security hazards that included an unlocked garden gate, an open exit door and a stairway that people could have access to from the ground floor and that were not risk assessed. There was unsecured lift equipment. The registered manager addressed these concerns when we pointed these to them.

Some people were assessed as not being able to use their call bells and measures had been put in place to check on them. However, there were other people who could use their call bells but these were not left in people's reach. This meant they could not call care staff promptly in an emergency.

People’s confidential archived information was not being kept in a secure manner.

People and relatives described care staff as “friendly” and “kind” we saw some compassionate interactions by individual care workers. However, we observed care staff did not always try to engage people who did not readily communicate and the provider was not enabling staff to meet people’s wishes in accordance with their care plan.

Staff could tell us how they recognised signs and symptoms of abuse and the registered manager had an oversight of accidents, incidents and safeguarding concerns. Where mistakes had been made lessons were learnt and shared with the staff team to help prevent a reoccurrence.

Medicines were administered in a safe manner and were audited regularly by the management team. There was good clinical oversight by the registered manager and deputy manager. They also ensured that infection control measures were robust in the home.

The provider undertook pre- assessment visits to meet with people and assess their support needs. These informed person centred care plans that stated people’s preferences and support needs. Where a risk to the person was identified, a risk assessment was completed with measures for staff to take to minimise the risks.

People were supported at the end of their life. There was partnership working with the palliative care nurse to provide effective and appropriate care to people. However, staff had not received end of life training and whilst the were end of life plans in place these did not always take into account people’s social, cultural and religious preferences. We have made a recommendation that the provider review best practice in gaining people’s views about their end of life wishes.

Nurses worked in partnership with visiting health care professionals to provide good access to health care for people living in the service.

The registered manager was working in line with the Mental Capacity Act 2005 (MCA) and ensured applications under the Deprivation of Liberty Safeguards (DoLS) were made in a timely manner where people were being deprived of their liberty. We observed care staff asking people’s permission before offering care and support and staff could tell us how they gave people choices.

There was a varied menu available and people were supported to eat well and drink enough to remain hydrated.

The provider had a clear vision about the way they operated the service that was shared with people, relatives and staff.

We found four breaches of regulations in relation to, person-centred care, staffing, safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

In March 2017 we received information from the local authority’s Environmental Health team and the Clinical Commissioning Group’s (CCG) infection control lead, following an outbreak of norovirus that affected people using the service and staff. The reports included a number of recommendations and actions for the provider to take to improve infection control in the service. At this inspection we found the provider had responded to the reports and had taken appropriate actions to improve infection control.

This report only covers our findings in relation to these topics. 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.

Norwood Green Care Home provides accommodation, nursing and personal care for up to 92 older people, some of whom were living with dementia. The service is provided by Four Seasons (No 7) Ltd, a private company managing over 300 care homes in the UK.

The service had a manager who was registered with the Care Quality Commission (CQC). 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.

We found that the provider was continuing to breach Regulation 15 and was also in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People using the service did not receive care and support in line with their preferences and their care plan.

The provider had not carried out works to upgrade the bathrooms and shower rooms and most people using the service had not had access to a bath or shower since our last inspection in July 2016.

The provider had taken appropriate action to implement recommendations made by the Clinical Commissioning Group (CCG) and the local authority to improve infection control in the service.

You can see what action we told the provider to take at the back of the full version of the report.

Norwood Green Care Home provides accommodation, nursing and personal care for up to 92 older people, some of whom were living with dementia. When we visited, 85 people were using the service. The service is provided by Four Seasons (No 7) Ltd, a private company managing over 300 care homes in the UK. The service had a manager who was registered with the Care Quality Commission (CQC). 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.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not maintain satisfactorily all parts of the premises and most bath and shower rooms were not fit for purpose. You can see what action we told the provider to take at the back of the full version of the report.

People using the service and their relatives told us people were cared for safely. Nurses and care staff were familiar with the provider’s safeguarding procedures and were able to tell us what they would do if they had any concerns about someone’s safety or wellbeing.

People received the medicines they needed safely.

The provider deployed sufficient numbers of staff to meet the care needs of people using the service. They had systems to ensure new staff were suitable to work with people using the service, although these were not always implemented consistently.

People using the service and their relatives told us staff were well-trained to meet people’s care needs.

The staff told us they felt well supported by the provider and managers in the service.

Managers and staff were working within the principles of the Mental Capacity Act 2005 and any conditions on authorisations to deprive a person of their liberty were being met.

Most people told us they enjoyed the food provided in the service.

People had access to the health care services they needed.

People using the service and their relatives told us the staff who cared for and supported them were caring and that they always treated people with respect.

We saw the staff caring for people were polite and kind.

The staff spoke a range of languages and they told me that at least one member of staff could speak the first language/preferred language of everyone who lived there.

People using the service and their relatives told us they received the care and support they needed.

Each person had a care plan that included an assessment of their health and social care needs.

People told us the provider arranged activities and outings and most people said they enjoyed these.

People also told us their family members and friends could visit them and they told us they looked forward to and enjoyed these visits.

The service had a manager who was registered with the Care Quality Commission. People using the service, their visitors and staff spoke positively about the manager.

Throughout the inspection, the atmosphere in the service was open, welcoming and inclusive.

The provider had systems to monitor quality in the service and to make improvements.

People's needs were assessed and care plans developed that ensured people's needs were met effectively. Any identified risks to people's welfare were assessed and plans put in place to minimise these while enabling people to maintain their independence. People's healthcare needs were monitored and met with the support of healthcare professionals.

People told us they were well looked after. Comments from people using the service included, 'They are nice people, I get on well with them all', 'they are very good and very kind, the staff are excellent' and 'it's lovely here and everyone is nice'. A relative said they were 'completely satisfied with the care (their relative) is getting'.

People were monitored and supported with their dietary and nutritional needs.

Equipment was available to meet people's needs, regularly risk assessed and appropriately maintained to make sure it was safe for people to use.

Staff received training and supervision to ensure they were appropriately supported in their job.

Overall people's personal records were accurate and fit for purpose.

People told us that staff treated them with respect and that they had choices in all aspects of their daily lives. We observed staff speaking with people in a gentle and courteous manner.

On the dementia units we observed staff engaging and interacting with people to promote their well being. One person said 'it's home from home and that it is a family within a family.' Another commented 'no problem, superb each and everyone (staff) is very good.' A relative told us that staff were 'well mannered, caring and professional'.

We observed people being administered their medicines by staff. The health care professional told us that staff were good at monitoring people's condition and the side effects of medication.

People we spoke with said they were confident to report any concerns or complaints to the manager and the staff.