Normanhurst Residential 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 registered under the current legal provider. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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 positive and open learning culture that supported safety. Staff understood how to recognise, record and report incidents and accidents, and managers reviewed these to identify learning and reduce the risk of recurrence. Incidents were recorded on the digital care record system and reviewed by the manager, with outcomes and learning shared with staff through team briefings.

Managers completed investigations and root cause analyses where required, including for medication errors and safeguarding concerns, and shared learning with staff through team briefings to improve practice and reduce repeat incidents. Complaints about safety were logged, reviewed and responded to in line with the provider’s policy, with actions taken to address concerns. Staff told us they felt supported to report mistakes and understood the importance of learning rather than blame.

Incidents and accidents were recognised and acted upon. For example, where people had experienced falls, staff introduced measures such as sensor mats to support safety and monitor risks. One person said, “I did fall over the arm of the chair. I have a sensor mat which rings if I tread on it and staff come to see me.”

The provider ensured people experienced safe and well-coordinated transitions into and within the service. Preadmission assessments and care plans were completed, and risk assessments were updated to reflect changes in people’s needs following admission or discharge from hospital.

The provider made referrals to health professionals when people’s needs changed. This meant staff had clear, up to date guidance to support people safely, particularly following changes in mobility or health. The registered manager monitored visits and engagement with health professionals within daily records.

Staff worked with health professionals when people’s needs changed, including contacting GPs and emergency services when required. A relative explained, “When [person] was unwell, they rang the GP and paramedics.”

The provider had effective safeguarding systems in place and people were protected from the risk of abuse.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the capacity to do so themselves. Staff demonstrated an understanding of the MCA and their responsibilities to support people to make decisions wherever possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty. The provider ensured applications were monitored using a tracker.

Safeguarding concerns were recorded and reported to the local authority, and staff understood how to raise concerns. Relatives confirmed safeguarding referrals were made when required. People generally said they felt safe and knew who to speak to if they had concerns.

The provider did not always work effectively with people to manage risks in line with their preferences. Risk assessments and care plans were in place, however people’s concerns or changes in health were not consistently identified or recorded which limited the providers ability to respond effectively.

Some people told us they were not fully involved in decisions about risk management, such as the use of sensor mats. One person said, “They’ve not really spoken to me about it. They’re getting a bit more relaxed with me now. What concerns me are the wires and pads as I’m frightened of tripping.” While some people felt reassured by staff responses, the lack of consistent involvement meant risk management was not always person centred. Following the inspection, the provider worked with the person to establish clear strategies to reduce the risk whilst promoting their independence.

Daily records did not always reflect agreed risk management strategies, which meant staff guidance was not always clear or consistent. For example, one person had a diagnosis of pre-diabetes, indicating an increased risk of developing diabetes. This was not consistently recorded in their care plan and there was limited evidence of action taken to support them to manage this risk, such as discussing foods with a high sugar content and the impact these may have on their health. This increased the risk that care was not always delivered in a way that balanced safety with people’s choice and independence.

The provider maintained a safe environment for people. Regular health and safety checks, audits and servicing of equipment were carried out, including fire safety checks, water temperature monitoring and Legionella controls. Fire risk assessments were completed and identified actions had been addressed.

Staff received training in fire safety and manual handling. Premises were well maintained, and risks were identified and managed through audits and action plans. Where issues were identified, such as equipment servicing or environmental hazards, actions were recorded and followed up. Handrails were fitted at appropriate heights and equipment such as walking frames was readily available.

The provider ensured there were enough skilled and experienced staff to keep people safe. Staffing levels were planned using a dependency tool that was reviewed regularly and reflected people’s needs.

Staff told us there were sufficient staff on shift and that managers were visible and supportive. There were enough staff on duty to meet people’s needs, including at night and weekends. People said help was available when needed, and relatives confirmed staffing levels were sufficient. One relative said, “There is always enough people, I never seen it short staffed.” Staff worked together to support people and responded to call bells in a timely way.

Recruitment processes were robust, with appropriate checks completed before staff started work. Staff received induction, training and supervision. Overall, staff were supported to work safely and meet people’s needs.

The provider had effective systems to prevent and control infection. Policies were in place and staff received regular training, including hand hygiene and use of personal protective equipment (PPE). Audits were completed regularly and included photographic evidence, with actions identified and addressed.

The environment was clean and hygienic, with appropriate facilities to support infection control. Staff followed best practice, including being bare below the elbow, and PPE was readily available. Information about infection risks was recorded in care plans where needed.

People told us staff wore PPE during personal care. Relatives also described the home as consistently clean and free from unpleasant odours.

Medicines were generally managed safely, with systems in place for ordering, storing, administering and recording medicines. Staff had received training and medicines records were completed, including for controlled drugs, where appropriate checks and oversight were in place. People received their medicines as prescribed, and no concerns were identified in relation to administration or safety of medicines in practice.

However, we found inconsistencies in systems to assure safe medicines management. For example, one person was prescribed rescue medication for epilepsy. The care plan did not contain clear guidance on what to do in the event of a seizure. There were no recorded seizure events for this person, and although staff were able to access relevant information, this was not consistently reflected across care planning documentation. Since the inspection, the provider has improved practice by ensuring this guidance is consistently cross-referenced across systems.

These issues did not impact on people receiving their medicines safely, but they limited the provider’s ability to demonstrate consistent oversight and assurance that medicines were always managed in line with best practice.