Norwood Green 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.

This is the first assessment for this service. This key question has been rated good. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

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 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.

The provider promoted a shared culture based on clear values, learning and accountability. Policies supported equality, diversity and professional conduct, and leaders consistently reinforced expectations around safety, dignity and person‑centred care through induction, supervision and regular meetings. Staff understood how the service’s vision and values applied to their roles and reflected these in day‑to‑day practice.

The provider demonstrated a learning culture focused on improvement. Quality audits, incident analysis and shared learning were used to identify themes, address risks and improve practice. Managers followed up actions through supervision and monitoring, encouraged staff to speak up and supported development within a diverse workforce. This helped embed continuous improvement and supported better outcomes for people.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was a current registered manager in post. Staff told inspectors leaders were approachable and supportive, and people and relatives described managers as responsive and open when concerns were raised.

Recruitment records showed leaders were appointed in line with Schedule 3 and Fit and Proper Person Requirements. Induction, supervision and training records demonstrated leaders received regular support and ongoing development, which helped them lead confidently and consistently.

Managers acted with honesty and integrity. They understood and applied the duty of candour, sharing information openly with people and relatives when things went wrong.

Managers carried out regular audits, spot checks and walkarounds to monitor culture and quality. Where concerns were identified, they acted through shared learning, supervision and follow‑up checks. Staff said managers noticed issues and acted on them, supporting continuous improvement and inclusive leadership.

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

Staff meeting minutes, supervisions and discussions showed staff were encouraged to share feedback and raise issues about practice, safety and quality. Staff told inspectors they felt listened to and confident that managers would take concerns seriously and act on them.

The provider had clear policies in place for freedom to speak up, whistleblowing and complaints, which were aligned with best practice. The whistleblowing policy clearly set out how staff could raise concerns internally or externally, reassured staff they would be protected from victimisation and explained investigation and feedback processes. Staff were directed to these routes through induction and the staff handbook, and managers confirmed they reinforced this regularly.

Managers investigated concerns and incidents sensitively and confidentially. Investigation records and shared learning showed managers reviewed events, identified themes and shared lessons with staff to prevent recurrence. Where concerns were raised, managers acted through supervision, training or changes to practice, demonstrating learning rather than blame.

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.

Policies aligned with current guidance set clear expectations about fair treatment, respect for protected characteristics and inclusive working.

The provider supported workforce wellbeing through accessible arrangements for staff. These included flexible working options, carers’ leave and wellbeing support, alongside recognition initiatives that helped staff feel valued.

Staff completed equality and diversity training as part of mandatory learning. This supported understanding of protected characteristics, bullying and harassment, and appropriate workplace behaviour.

The provider made reasonable adjustments where needed and enabled staff to raise concerns safely. Leaders acted on issues raised and used staff feedback from meetings, surveys and supervisions to inform improvement, supporting an inclusive culture.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were robust quality assurance systems in place. Monthly clinical governance audits were undertaken to ensure the quality of services provided and to ensure people’s safety. For example, various audits were completed such as medicines, infection control, accidents and incidents and analysed to identify any emerging trends to take appropriate action to address them.

Rotas, recruitment, training and performance systems supported staffing needs, and records showed investment in recruitment and resources to maintain service continuity.

Leaders shared policies and procedures clearly with staff and people through induction, training and meetings. Systems were in place to protect personal data and support compliance with data protection requirements.

The provider managed risk and emergencies effectively. Business continuity plans set out actions for incidents such as fire or loss of utilities, and systems ensured statutory and regulatory notifications were made when required.

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 provider used clear referral processes to support joined‑up working. Staff made timely referrals to community health and specialist services, and records showed these were followed up to support continuity of care.

The service communicated effectively with community partners. Records showed staff accessed learning and training through the local authority and shared relevant learning within the service to improve practice.

People, relatives and staff were involved in partnership working. Families were informed about referrals and outcomes, and records showed shared learning from professionals was discussed with staff to support consistent care.

Policies and action planning emphasised collaboration and improvement. Business planning reflected the importance of partnership working and staff development to improve outcomes for people.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

Managers used audits and oversight to identify risks and areas for improvement. They shared learning from incidents to improve practice and reduce repeat concerns.

Staff learning was supported through training and supervision. Learning from audits and external guidance was shared with staff to strengthen consistency and safety.

Leaders reviewed action plans and feedback to monitor improvement. They used information from staff, people and relatives to inform next steps and drive ongoing improvement.