Normanhurst Residential 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 registered under a different legal provider. This key question has been rated requires improvement.

The service was led with a positive culture and staff who felt supported by leaders. Systems for monitoring quality and safety were in place, and audits were regularly completed. However, these systems did not always identify the issues found during the assessment and was in breach of legal regulation in relation to governance at the service.

This service scored 61 (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 did not always have a clear, consistently shared vision and culture that was fully understood and embedded across the service. Leaders had defined values and a mission statement which promoted equality, respect and accountability. Staff were aware of these values and managers described efforts to model them through open communication and a hands‑on leadership approach. However, this was not always reflected in practice.

Leaders had introduced new systems, trackers and policies to strengthen oversight and improvement, although these changes were not consistently embedded or effective. There were also inconsistencies between leaders’ understanding of people’s experiences and the feedback provided by people using the service, indicating that the shared culture was not always informed by lived experience. However, leaders promoted an open culture and showed commitment to both staff and people using the service. Managers described how they balanced a range of responsibilities, including administrative tasks and direct oversight. This demonstrated flexibility and responsiveness to the needs of the service.

Overall, while the provider had articulated a positive vision and values, these were not always effectively implemented or consistently reflected in people’s experiences of care.

Some people and relatives described positive experiences of care and felt staff knew them well. However, others told us they did not feel consulted or involved in decisions about their care and were unclear about how their views influenced how the service was run. People said they did not know whether changes were made as a result of residents’ meetings.

The provider had leaders who were visible, approachable and understood the context in which care was delivered. Staff consistently described managers as supportive, responsive and willing to work alongside them, including attending the service at different times to provide oversight and reassurance. Leaders demonstrated commitment to integrity and openness, including responding directly to incidents, complaints and staff concerns.

There were systems in place for audits, supervision and provider oversight, and leaders used these to identify risks and areas for development. Managers promoted teamwork and problem‑solving, encouraged staff to reflect on practice and supported learning following incidents. Staff feedback indicated trust in leaders and confidence that concerns would be taken seriously.

Some people described seeing the registered manager regularly and felt senior staff were supportive and helpful. Relatives spoke positively about the leadership team and gave examples of managers responding to individual needs, such as supporting with technology and liaising with health professionals.

Although some governance systems required strengthening, leaders had the credibility, skills and compassion needed to lead the service and were actively engaged in supporting both staff and people using the service.

The provider fostered a culture where staff felt able to speak up and raise concerns. Staff described managers as accessible, with an open‑door approach and encouragement to raise issues informally or formally. Examples were provided where staff feedback had resulted in prompt action, such as resolving equipment shortages.

Clear policies were in place for whistleblowing, bullying and complaints, which outlined escalation routes internally and externally. These policies were up to date and accessible to staff. Leaders shared learning from incidents and investigations, including root cause analyses, during team briefings and handovers, which helped reinforce openness and transparency.

Overall, staff felt confident their voices would be heard and that speaking up would lead to learning and improvement rather than blame.

The provider valued diversity within its workforce and promoted an inclusive and fair culture. Policies and employment practices supported equality, flexible working and family‑friendly arrangements. Staff had access to equality and diversity training, and leaders demonstrated awareness of protected characteristics and individual circumstances.

There was evidence of reasonable adjustments being made to support staff wellbeing, including flexible rotas, phased returns to work and adjustments following illness. Managers encouraged staff development through qualifications and champion roles, supporting progression and inclusion. Overall, leaders worked towards improving equality and equity for staff and promoted a respectful, inclusive working environment.

The provider did not have effective governance systems in place to ensure consistent oversight, accountability, and timely action. Although a range of audits, trackers, and monitoring processes were in place, these were not operating effectively. Risks were identified, although action to address these was not consistently timely or sufficiently robust.

Oversight of care planning was inconsistent. Systems had not ensured updates in care plans consistently reflected people’s current needs or that people were always involved in decisions about their care. There were discrepancies between people’s lived experiences and the records reviewed, indicating governance arrangements were not accurately capturing or responding to how care was delivered, including around consent and risk management.

Leaders recognised that the transition from paper-based to digital systems had created challenges, with information spread across multiple platforms. Leaders recognised that some information was spread across multiple different platforms. This reduced clarity and limited leaders’ ability to maintain effective oversight and respond consistently to identified issues, particularly in person-centred decision making.

While leaders had identified these concerns and had started to simplify systems and improve oversight through strengthened dashboards, governance arrangements remained ineffective and did not provide assurances of safe, high-quality, and sustainable care.

The provider worked constructively with a range of external partners and community organisations to support people’s care and wellbeing. There was evidence of positive relationships with GPs, allied health professionals, local authority teams and specialist services, including Speech and Language Therapists and community nursing teams. Weekly GP rounds supported continuity and timely decision‑making. Staff and managers shared learning from partner involvement and welcomed external advice and recommendations. Relatives described effective communication with GPs, paramedics and district nurses when people became unwell.

Leaders actively sought opportunities for community engagement, including intergenerational projects, faith‑based links and local community groups. These partnerships helped ensure care was joined‑up and responsive, supporting people to remain connected to their local community.

The provider did not always demonstrate a consistent focus on continuous learning, innovation and improvement. While audits, reviews and incident analyses were undertaken, learning was not always embedded into practice or used to deliver sustained improvement. Systems were not always effective and had failed to identify or address the concerns found during this inspection.

Feedback from people about activities and involvement had not been identified or addressed. This indicated that learning was not always embedded into practice and that opportunities to improve people’s experiences were sometimes missed. Since the inspection, the provider undertook further audits, developed action plans and implemented changes in response to people’s feedback.

Leaders had begun to reflect on this and were taking steps to simplify processes, improve dashboards and strengthen trend analysis. There was evidence of learning from external reviews, such as environmental assessments, and some improvements had been made in response. However, innovation was not yet systematic or consistently linked to improved outcomes for people.

Overall, the provider was at an early stage of strengthening a culture of continuous improvement and innovation.