Norwood Guest House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learned to continually identify and embed good practice.

The registered manager had oversight of accidents and incidents, with records demonstrating action was taken to investigate and ensure lessons were learned. The registered manager told us they had created an open culture where staff could report concerns without fear and aimed to drive improvement. Staff told us they felt able to raise any concerns if needed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager and staff team had good relationships with external services and supported emergency placements where people’s living situations had been at risk of breakdown. Staff took time to support people as they arrived at and left the service during periods of respite, ensuring people’s transitions went as smoothly as possible.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. Staff focused on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider had safeguarding processes in place, and staff completed training in this area. The registered manager had oversight of safeguarding concerns and worked with the local authority to investigate any issues and took measures to reduce future risk.

Where people did not have capacity and were subject to restrictions, the registered manager had made applications under the Deprivation of Liberty Safeguards.

The provider did not always work effectively with people to understand and manage risks. However, staff provided care that was safe, supportive, and enabled people to do the things that mattered to them. Overall, people and their families felt the service was safely run and that people were well cared for during their visits.

We identified some concerns regarding how people were able to seek support from staff when in their bedrooms, as there was no alert system in place. We asked the provider to review this to ensure people were able to readily access staff support when in their bedroom or bathroom, in a way that was tailored to their individual needs.

People had access to information, including risk assessments and support plans, and work was ongoing to improve the quality and level of detail within these records. However, staff demonstrated a good understanding of people’s needs and how these should be met.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found maintenance and checks were completed on the building and equipment, but these had not always led to timely action being taken. For example, we found delays in addressing areas identified in the fire risk assessment, and some large pieces of equipment were not suitably secured to the wall to prevent risk. The registered manager took timely action to address these concerns when they were raised with them.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked well together to provide safe care that met people’s individual needs.

Staff told us they worked well together and felt they had the skills and training needed to provide safe care and treatment. We found some shortfalls in the training records, but the registered manager provided assurances that these gaps were due to missing information and work was underway to ensure accurate oversight of training would be maintained. We saw evidence of a full induction, with staff receiving supervision and feeling well supported.

The registered manager was looking at developing records to manage staff appraisals, as the provider had recently lost some of its human resources support. Further input from the provider was needed to ensure oversight of training, and that processes for induction, ongoing training and competency assessments were in place and effective following these changes. This was addressed following the inspection.

Feedback from parents indicated that they were not always confident that all staff knew how to support people, with one person commenting, “The problem they are having is a changeover in staff. The training has to be renewed so they have the knowledge.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The premises were kept clean and tidy, with the domestic staff working throughout the day to ensure deep cleaning was completed. Staff completed training in this area, and the registered manager carried out observations of staff practice, including handwashing and the donning and doffing of personal protective equipment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Further work was needed to ensure systems for the storage and management of medicines were suitably robust. The registered manager was responsive to feedback and took immediate action to ensure oversight of the temperatures at which medicines were stored was maintained, and to improve the records in relation to medicine administration. Medicines were given to people as needed, and staff received training in this area and had competency assessments as required.