Norway Lodge Nursing 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 remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted 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 and leaders fostered a positive culture which was inclusive, person centred, empowering and focused on the provision of high-quality compassionate care. This culture was both understood and practiced by staff. An external professional commented, “The service appears to run in an organised manner, with an emphasis on safety, transparency, and person-centred values.”

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. Leaders and managers were available, consistent and led by example.

The registered manager had been based at the service since its opening and was highly thought of by people and staff. One person told us, “I know the manager and its well-run here.” A relative commented, “[Manager’s Name] is marvellous, she is excellent the way she runs the home and couldn’t be more helpful.” An external professional confirmed, “The management team appears approachable, visible, and proactive in their oversight of the service.” Staff understood the vision and strategy of the service and leaders had the experience and capability to help ensure the strategy was delivered.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems and processes enabled people, relatives and staff to express their views, including meetings and surveys. We reviewed written surveys completed by people’s relatives and found positive comments, for example, “All staff are great, the home is always clean and smells nice. Couldn’t ask for a better home for my dad” and “Mum’s care has been excellent, and staff make it a home. They are friendly and helpful, I can’t ask for more.”

We observed staff meetings did not always take place with regularity, we spoke to the registered manager about this who confirmed this was something they intended to address. However, the registered manager had a strong visibility in the home and operated an open-door policy, staff were able to voice any concerns they had at any time. One member of staff told us, “I feel I have a voice here and the manager is very approachable.” People and family members told us they felt comfortable raising issues and believed staff and managers would listen and respond.

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. Equality and diversity were actively promoted, and processes were in place to help ensure staff felt treated equitably. Staff told us they felt respected, valued and supported.

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. The provider had effective governance, management and accountability arrangements.

Although some policies were outdated and some required further detail, the registered manager provided assurances they would be revised and updated. Governance processes helped to identify and manage risks to the safety and quality of the service. These processes were used to drive up the quality of the service. The registered manager told us they felt fully supported by the provider and had access to the resources they needed to run the service effectively.

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 was open and collaborative with relevant stakeholders. It worked in partnership to help support care provision and joined up care. One external professional told us, “Staff are always co-operative and happy to take advice and act on it."

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Quality assurance arrangements were in place to help identify any areas for improvement. Leaders considered information about the service’s performance and how it could be used to make the required improvements.

Lessons were learned following incidents and safeguarding concerns to help support improvements in practice. During the inspection process, the registered manager acted promptly to address issues we raised in relation to the environment and records, demonstrating a commitment to continuous improvement.