Normanhurst 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 Good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to governance.

This service scored 61 (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.

There was a positive culture at the home. All staff were committed to developing the home for people, to improve their quality of life, their outcomes and making it a good place to live. One staff member told us, “I’m part of staff team, I fit in.” Another staff member said, “I enjoy it here. I feel well supported.”

The provider had leaders who understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation. However, improvements were needed to ensure they had the skills, knowledge, experience and credibility to lead effectively with integrity, openness and honesty.

There was a management structure at the home. The registered manager was supported by a team leader and senior care staff. The team leader and senior care staff were responsible for the smooth running of each shift. Staff told us they felt supported by the registered manager and colleagues. Although leaders responded when concerns were shared and identified, a lack of robust systems and processes meant we could not be assured concerns would always be promptly identified and addressed within the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff understood whistle-blowing policy and told us how they would report any concerns internally. They told us they could always speak with the registered manager, the provider and duty managers within the administration office. One staff member said, “It wouldn't bother me, I would whistleblow if I needed to. People should be treated the same way you would treat your family.”

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 received training in equality and diversity. They told us they could share concerns and ideas through supervisions and team meetings. Staff told us they felt valued and everyone worked well together. Staff said their individual needs and culture were respected, and they gave us examples of this.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have effective systems in place to monitor the quality of service and the running of the home. The lack of safe storage for oxygen had not been identified and was not addressed until identified at inspection.

The provider has a statutory responsibility to notify CQC about certain changes, events and incidents that affect their service or the people who use it. We identified 2 occasions where systems to assure these notifications were submitted to CQC had failed.

The electronic care planning system identified when care plan reviews were required. Although these were completed people’s records did not always include current and relevant information. There was no system to identify the quality and completeness of the care plans and risk assessments. For example, mental capacity assessments did not include the person, or their representative’s voice. There was no system to identify when relevant care plans or risk assessments were not in place. This also meant that when an incident occurred, which was related to a risk, these incidents were not recorded because there was no guidance for staff.

Where areas for improvements in relations to medicines were identified, these improvements were not always implemented or not implemented in a timely way. Although staff had received training there was no system which provided full oversight of what training staff had received. There was no system to identify what training staff needed to meet the needs of people currently living at the home.

Staff who were responsible for writing and reviewing care plans told us they were not confident using the electronic care planning system. They told us this accounted for some care plans that did not include up to date information. The registered manager told us this was not a system they had used before, and it had been introduced prior to them joining the service. They recognised staff may need further training on the system, but this had not been implemented at the time of the inspection.

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.

The registered manager and staff team had developed positive working relationships with services who supported people living at the home. This was seen through the records viewed. Staff told us how they would contact relevant external professionals to help them meet people’s changing and ongoing needs. We received limited feedback from health and social care professionals who visited the service. This was generally positive.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

Although there was evidence of learning from some incidents, we found improvements were needed to strengthen quality assurance processes. The systems in place were not effective and had not identified all concerns to drive improvements. This meant learning opportunities were missed. Improvements to these systems would help ensure the service was able to identify concerns promptly and continually improve.