Norton Lodge

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 inadequate. 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 provider was in continued breach of legal regulation in relation to good governance.

This service scored 62 (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 not fully embedded a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Since our last assessment, the provider had introduced systems to gather feedback from people and enable the management to share information. However, some family members and staff fedback they were not yet fully confident the positive changes seen would be sustained. Despite this, most staff told us they felt much more settled and positive about working at the service. Comments included, “Things are a lot better since the new company started” and “I like coming into work now, well I’m taking on extra hours so I must do.” Family members told us the provider had been open and transparent about the failings identified at our last assessment and their commitment to improve.

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. A new manager had been recruited at Norton Lodge who was in the process of registering with CQC. Staff spoke positively of this appointment. Comments included, “[Name] has brought a whole different vibe. We are involved in some decision making. Staff are a lot happier, and it is a bit more relaxed” and “It makes a massive difference if you speak to a manager and things get done, it feels like you are being listen to and valued.” The manager had been supported by the provider to drive the improvements needed at Norton Lodge.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had policies and procedures in place which guided staff through the process to speak up. Staff told us they felt confident to speak with the new management team and felt they would be supported through this process. Staff feedback included, “Since [Name] has been here it’s been completely different home, it’s more relaxed” and “[Name] the new manager is more approachable.”

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 and procedures were in place to ensure staff were treated fairly and equitably. This included when they had protected characteristics under the Equality Act 2010.

The provider had introduced new responsibilities, roles, systems of accountability and good governance since our last assessment. However, these were not all fully embedded. The shortfalls we identified had not always been picked up through the provider audits. Some governance systems had not been consistently recorded so the provider was unable to demonstrate how the systems had supported the delivery of good quality, sustainable care, treatment and support. For example, not all care plans had been audited since they had been rewritten. We found inconsistencies in the level of detail and quality which needed further work. The manager completed a daily walk round of the environment, and regular meetings were held between staff to discuss people’s needs. These systems were not consistency recorded. Improvements were needed to improve the cleanliness of the home and to the outside areas to improve safety. The manager had picked up on some issues through their walk round, however, as these were not consistently recorded, we were not able to see a clear plan of action had been formulated to address any issues. Provider checks had failed to identify all of the concerns we raised. Following our assessment, we did receive a full refurbishment and environment improvement plan, which included progress and targeted dates for completion.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The manager was working closely with other professionals and taking proactive steps to improve collaborative working between services. Partners who worked with the service told us partnership working had greatly improved, and the manager was proactive and unafraid to challenge to seek the best outcomes for people. Family members felt more involved and informed. One family member told us, “There has been an improvement in the way that I am kept informed by the manager. Communication is good and they will ring me if there is an incident.”

The provider had systems to focus on continuous learning, innovation and improvement across the organisation. Provider newsletters had been developed to share learning and best practice. Systems to demonstrate learning and improving from events which occurred had improved. Regular meetings with people and their family members had been introduced. This included a weekly meeting with people to discuss activities. A staff member told us, “If someone made a suggestion, we would do it. I sit with residents on a Friday morning to see what activities we can do.” Feedback through a satisfaction survey was being gathered as another method of gathering views of Norton Lodge. Staff were being supported through supervision and team meetings.