Norwood Green Care Home

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 service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 learnt to continually identify and embed good practice.

Managers addressed recording issues through supervision and refresher training, which improved the timeliness and quality of reporting.

Managers investigated safety events and completed root cause analysis for repeated or complex incidents. Following the inspection, the provider shared learning tool that captured learning from feedback received from inspectors. This showed agreed actions and expectations shared with staff. Learning was reinforced through handovers and meetings, helping staff understand how changes in practice reduced risks to people.

The provider reviewed incidents, complaints and inspection findings to drive improvement. Managers identified themes, such as fire safety, meal recording and personal care standards, and tracked actions through improvement plans with clear ownership and timescales.

Ongoing monitoring and spot checks supported more consistent practice and clearer documentation.

Managers followed a duty of candour approach and supported staff to raise concerns. Training in safeguarding, duty of candour and whistleblowing reinforced a blame‑free culture. Induction, supervision and post‑incident support encouraged openness, embedded learning and reduced the risk of recurrence.

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

Managers completed pre‑admission assessments and gathered information from local authorities, hospitals and healthcare professionals to confirm they could meet people’s needs before admission.

People and relatives received guidance to support them when moving into the service. This explained what to expect and the support available during admission. People and relatives described transitions as smooth and reassuring, including admissions from hospital. One relative said, “The hospital was involved, it was fine,” and another told inspectors, “It felt like home straight away.”

Pre‑assessment paperwork was comprehensive and person‑centred. Assessments covered health, communication, mobility, risks and preferences. Where people lacked capacity, staff completed Mental Capacity Act assessments and recorded best‑interest decisions, involving relatives and professionals as appropriate. Care plans were developed from these assessments and shared with staff through electronic records and handovers, supporting continuity of care.

Staff communicated people’s needs effectively when they moved into the service or returned from hospital. Handover notes and care plans highlighted key risks and support needs. Staff told inspectors they received good handovers and felt confident supporting people during transitions. Referral records showed timely referrals to GPs, therapists and local authority teams, supporting joined‑up care and reducing risks during changes in care pathways.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Safeguarding approaches considered people’s views and involved health and social care partners where appropriate.

People, relatives and staff had access to safeguarding information that explained what abuse looks like and how to raise concerns. Staff spoken with understood their safeguarding responsibilities and felt confident to speak up. One staff member described recognising signs such as unexplained bruising or neglect and said they would challenge poor practice, and report concerns to a senior immediately.

The provider had clear processes to record, investigate and respond to safeguarding concerns. Staff understood how to escalate concerns promptly, including following incidents such as falls. Records showed managers took action to protect people and involved external agencies when required. Staff described working as a team and sharing observations with senior staff so concerns could be addressed and care plans updated.

Managers had oversight of safeguarding activity and learning. They monitored concerns and incidents, reviewed themes and ensured appropriate notifications were made to the local authority and CQC when required. Managers followed a duty of candour approach and kept people and their relatives informed. Learning from incidents was shared with staff to reduce recurrence and improve practice.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care records showed staff explained risks and sought people’s views before providing support. Where people declined care, staff respected this and continued proportionate monitoring. One person said, “I am OK, my skin is fine,” which staff recorded and responded to through ongoing observation and reassurance.

Risk assessments were person‑centred and informed clear guidance for staff. These covered key risks such as falls, mobility and health conditions and were reviewed when needs changed. Staff said they encouraged independence wherever possible and “step in only if there is a safety concern,” supporting least‑restrictive practice.

Daily records showed staff followed agreed risk strategies consistently. Records evidenced regular welfare checks, support with nutrition and hydration, and flexible responses when people declined care or activities. Staff adapted support while ensuring people remained safe, which helped maintain dignity and autonomy.

Staff understood their responsibilities for managing risk and escalation. They told inspectors they recorded refusals clearly and shared information during handovers to ensure consistent responses. This supported collaborative risk management, with people’s wishes central and safety maintained through proportionate, least‑restrictive approaches.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Systems were in place to identify issues and act promptly to maintain a safe environment.

People told inspectors they felt safe and able to move around independently. One person said, “I can move around here alright,” and another said, “If I ask them to fix it, they will.” Observations showed corridors had handrails, rooms were personalised, and mobility equipment was available, well maintained and stored correctly.

Environmental walkarounds and record reviews showed fire safety systems were in place and maintained. Fire extinguishers were in date, emergency lighting and carbon monoxide checks were completed, and fire drills were carried out. Fire exits were clearly marked and unobstructed, and water temperatures were checked and recorded to reduce scalding risk.

Personal emergency evacuation plans were accessible in grab bags and updated where needed. Managers used audits and walkarounds to identify issues such as unsecured cupboards or wear and tear, and staff understood how to escalate concerns and who was responsible for fire safety on each floor.

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

Recruitment files showed completed applications, verified identity, enhanced criminal checks, references and health declarations. These checks ensured staff were suitable and capable for their roles, resulting in people receiving care from appropriately vetted staff.

The provider deployed enough suitably skilled staff to meet people’s needs. Rotas and dependency tools showed staffing levels were adjusted when people’s needs changed, and staff responded promptly to call bells and requests. One person said, “There’s always someone about when you need help,” showing staffing arrangements were effective in practice.

The provider trained staff well so they could support people safely and confidently. Training included statutory training and specialist training such as learning disability and autism awareness, therapeutic engagement, and percutaneous endoscopic gastrostomy feeding delivered by NHS and community specialists. Staff applied this training in practice. One staff member said, “We get the right training when people’s needs change.”

Managers supported staff through regular supervision, appraisal and professional oversight. The supervision matrix showed planned and completed one‑to‑one meetings across roles, including nurses, care staff, senior carers and ancillary staff. Managers carried out relevant checks to ensure nursing staff were up to date with revalidation and their registrations were up to date.

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.

People told inspectors the home was clean and well maintained. One person said, “Two or three times a day they are cleaning,” and another said, “It’s nice and clean.” People also confirmed staff used personal protective equipment during personal care, which helped them feel protected.

Inspectors observed the premises were clean and free from unpleasant odours. Handwashing facilities were well stocked, personal protective equipment was readily available on each floor and used appropriately, and cleaning schedules showed regular and enhanced cleaning. Food hygiene checks, fridge cleaning and temperature monitoring were completed and recorded.

Domestic staff understood infection prevention and control procedures, including the safe use of cleaning products and waste disposal. Leaders completed infection prevention and control audits and followed up actions. Pest control records showed regular monitoring with no recent concerns, and leaders monitored practice through audits, observations and training to maintain safe standards.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were administered, recorded and reviewed appropriately, and staff were trained and supported to carry out these tasks safely. People received their medicines as prescribed, including those that were time‑critical.

Medicines were stored securely in locked cabinets and medication trolleys, with controlled drugs kept in a separate locked cupboard. Medicine room and fridge temperatures were checked and recorded daily, providing assurance that medicines were stored safely and remained effective.

Trained staff administered medicines in line with the provider’s medicines policy. Staff had completed competency assessments and received regular refresher training. Medication rounds were unhurried, and staff were observed checking Medication Administration Record (MAR) charts carefully before administering medicines. Records were generally accurate, with clear signatures and codes for non‑administration. PRN (as required) protocols were in place, although a small number of omissions lacked a recorded reason.

Managers maintained oversight of medicines management through regular audits. Systems were in place for ordering repeat prescriptions and liaising with local pharmacies, and medicines no longer required were disposed of safely with records maintained. Where audits identified issues, managers implemented action plans and followed these up, supporting continuous improvement in medicines optimisation.