Normanton Lodge Care 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

We identified 1 breach of the legal regulations under the safe key question. The service did not always learn from incidents or act to fully mitigate the potential risk of harm, including identifying and referring safeguarding concerns. It was not always clear if people and their relatives had been involved in reviewing care and support. Some minor improvements were required regarding medicines practice; however, we were assured people had received their medicines as prescribed. Overall, care plans contained sufficient guidance to support people safely. People were supported by enough trained and competent staff. The environment was clean and well-maintained. People and their relatives told us they felt safe using the service.

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.

We received mixed feedback on raising concerns about safety with management. Some people using the service did not know who to raise concerns with, others felt management were not always approachable. However, overall people and their relatives told us they felt save using the service. One relative told us, “[Person] is very safe, looked after very well, good, attentive staff, good security, never had to complain.”

We discussed some of the incidents which had been recorded and reported by staff but had no manager review. Leaders were not always able to demonstrate how they ensured incidents were appropriately investigated and reported. Leaders explained that improved documentation to support post-accident reviews was being implemented. Staff understood the provider’s accident reporting policy and procedure and were able to talk through how they would deal with accidents, incidents and falls.

Systems to review accidents and incidents impacting on the safety of people using the service were not effective. This placed service users at risk of harm as lessons were not always learned and action to mitigate risks were not always identified or implemented. Monthly reviews of accidents, incidents and falls did not suitably review or analyse themes and trends. For example, one review stated, ‘[Person] has had several falls out of bed but unsure why’. No further analysis into the cause of increase in falls for this person was carried out or any action identified to prevent further falls. Staff completed accident and incident forms; however, these did not always have a managers review. This meant we could not be assured leaders had adequate oversight of accidents and incidents at the service.

We discussed the admissions process with people and relatives. People and relatives told us they felt fully involved in this process. We received positive feedback about staff and steps they took to help people settle into the service, such as choosing a bedroom. One person told us, “My friend was staying here and so I knew what to expect. They let me choose my room and discussed what I wanted.”

Leaders who oversaw referrals and admissions explained they worked with a range of professionals to organise people’s care and support. Leaders told us of success stories about people supported to move between the 2 units as their support needs changed. For example, increased independence could mean they would be better suited in the Glen Care Unit, which consisted of self-contained apartments. This meant people still had the familiarity of the location and staff, meaning a smooth experience for them. Staff felt the information provided as people moved into the service through pre-admission assessments and care plans supported them to understand people’s risks.

Partner agencies confirmed the service worked collaboratively with them.

Systems and processes to identify and manage risks to people were not always proactive or effective. For example, a review of accidents and incidents identified a new admission had fallen frequently in one month. The review noted that the person had repeatedly fallen at home, however failed to consider whether appropriate risk assessments had been implemented or reviewed following their transition into the service to mitigate this known risk. Where additional support was required from relevant healthcare professionals, recommendations were clearly recorded within people’s care plans.

During our assessment, one person raised concerns with the inspection team which indicated potential abuse. We raised this with the local authority safeguarding team. Other people and relatives we spoke with did not raise any concerns about abuse or safety.

Whilst staff and leaders confirmed they had received safeguarding training and could explain their responsibilities to report and investigate safeguarding concerns, we could not be fully assured this was consistently implemented because we identified safeguarding concerns during our assessment.

People were observed to be comfortable and relaxed in the presence of staff and able to request support which was provided.

Systems and processes to ensure people were protected from the risk of potential abuse were not always effective. During our assessment we reviewed accidents and incidents and identified an incident which should have been referred to safeguarding. However, the registered manager had not completed a suitable review of this incident and therefore had not made the referral at the time or investigated the incident. We could not be assured any action had been taken to ensure people were protected from the risk of potential abuse. The provider had a safeguarding policy in place. Deprivation of liberty safeguards were applied for and monitored appropriately.

We received mixed feedback from people and relatives about their involvement in care planning. Some were unsure if a care plan was in place. Most were satisfied that people’s risks were suitably identified and assessed. One relative told us, “A care plan was discussed; they look after all [person’s] needs.” People and relatives, we spoke with felt staff understood people’s risks well and supported them safely, one relative said, “Yes I have seen a care plan, not sure if it has changed, staff understand [person] well.”

Leaders were working through care plans and risk assessments to ensure they were reflective of people’s needs. Staff knew people and their risks well. Staff were able to tell us how they supported individuals who communicated signs of distress, for example using distraction techniques.

Staff were observed to support people safely, and in line with their care and support plans. For example, using correct moving and handling techniques and equipment.

Whilst reviewed monthly by staff, care plans did not always show people and their families had been involved in the review process. Care plans and risk assessments were not always reviewed following a fall. This meant any action to mitigate falls risks were not always promptly identified. However, overall, we found care plans and risk assessments to suitably identify and assess clinical risks to people. For example, epilepsy care plans provided details on how a seizure may present and guidance for staff on how to safely support someone who is having a seizure. Care plans and risk assessments to support people who communicated signs of distress or required additional support to manage their mental health provided sufficient guidance for staff to support people safely. For example, one person’s care plan detailed how activities and entertainment improved a person’s emotional well-being

People and relatives felt the environment was safe and well-maintained. They confirmed people had access to any specialist equipment they needed. For example, “[Person’s] room is safe, they can use a wheelchair, armchairs and have crash mats in place.” Another said, “All [person’s] furniture is suitable and well thought out, they use a wheelchair and walking aid under supervision.” People told us they knew how to report any concerns in the environment and thought problems were dealt with appropriately.

Staff and leaders confirmed they had clear processes to report any concerns within the environment and that they would be dealt with promptly. Maintenance staff were diligent in their roles confirmed the provider ensured they had adequate support and resources to maintain a safe environment.

There was a lack of signage around the service, which would support people with cognitive impairments to navigate. However, people were observed to be supported in a safe environment and with access to specialist equipment as required. People had a choice of communal spaces, including quiet areas.

Systems and process to review the safety of equipment following accidents or incidents were not always effective. For example, following a failure of hoisting equipment leading to injury, we were not assured action was taken to ensure all equipment had been suitably checked after this incident. A continuity plan was in place to support the service in case the service was impacted, which included environmental risks. Further improvements were required to ensure this provided suitable detail and guidance in the event of an emergency. Routine health and safety checks were completed on the environment. There were clear processes for reporting environmental issues to the maintenance team.

Feedback from people and relatives was that staffing levels varied. Some noted that weekends there seemed to be less staff and staff often appeared busy. Another person said that if a service user is unwell this can impact on staff’s ability to see to people promptly. One person told us they had been told by staff not to use their call bell between 5am and 7am because it was a busy time for staff.

Overall staff felt there were enough staff to keep people safe. Staff spoke about working well as a team and providing support to each other. Staff fed back positively on the training they had received and felt it provided them with the necessary skills and knowledge to carry out their roles. Staff confirmed they received an induction when they started, and this included shadowing experienced staff before working independently. Staff confirmed they received support in the way of supervisions and team meetings. Leaders explained they were supported by the provider’s training manager who would provide service specific training.

Staff were present in communal areas and attended to people’s requests for support. There were occasions we observed staff ask if people could wait whilst they completed one task. Staff were busy but did not rush people.

Systems to calculate safe staffing levels were not always updated to reflect the needs or numbers of people using the service. At the time of our assessment, the most recent tools used were dated April and May 2024. This was updated following our site visit and staff rota’s showed staffing levels were appropriate for the needs of the service. A training matrix showed staff had completed training to carry out their roles. A training plan was in place for staff who’s training was due for renewal.

All people and relatives we spoke with felt the service was clean. One relative said, “Clean and tidy, no smell, accidents cleaned up quickly.” Many fed back positively about the domestic staff and confirmed they were visible around the home whenever they visited. For example, “Clean home, always a cleaner about.” And “Very clean and tidy, cleaners are so nice, can’t complain at all, no smells at all, lots of decorating going on.”

One staff member shared cleaning tasks were not always completed; however, this would be picked up by care staff or completed as soon as possible. Overall, staff felt they had the support and resources needed to keep the premises clean and free from infection. Staff were able to talk through how they would respond in the event of an infection outbreak and how practices may change. Staff confirmed they had received infection, prevention and control (IPC) training.

People were cared for in a clean environment. Staff were observed to wear correct personal protective equipment (PPE) in line with best practice guidance.

Some systems and processes to review infection control at the service were not always effective. The registered manager completed monthly checks of cleaning schedules; however, this had not identified that there were occasional gaps in these records. The provider had appropriate policies in place to support infection prevention and control (IPC). Staff had received IPC training.

One relative fed back that there had been occasions where medicines had run out and not re-ordered. However, overall people and relatives were satisfied that they received their prescribed medicines. People confirmed they were given pain relief as needed, “They do give me paracetamol if I have a headache.” Relatives confirmed staff kept them informed of any changes to people’s medicines, one said, “Medication is handled well, kept in a locked cupboard, issued in containers, I am informed of any changes.”

Staff followed best practice guidance when administering medicines and overall demonstrated a good understanding of people’s needs relating to medicines. For example, where people required their medicines at a specific time or with specific instruction, these were kept in a priority trolley and administered before other medicines. Staff understood the medicine error reporting process and what to do in the event of a medicines error. Staff confirmed they received training and regular assessments of their competency to administer medicines. Staff were receptive to feedback on areas for improvement relating to medicine administration. Leaders explained they were in the process of sourcing and arranging an external medicines audit with the local pharmacy.

Systems and process to review medicines at the service were not always effective. Medicine audits were completed monthly but failed to identify some of the areas for improvement we found during our assessment. For example, gaps in fridge temperature records and missing body maps for topical creams. Where people required medicine to manage behaviour, protocols to support staff in administering the medicine did not always provide sufficient information on when this medicine should be given. For example, one person’s protocol noted ‘agitation’ as a reason for administration. Whilst staff were able to explain what this looked like for the individual, this was not recorded and therefore increased the risk of this medicine being administered inappropriately. We did not find any evidence this impacted on people receiving their medicines as prescribed. Medicines were stored safely. Where people required medicines to be administered covertly, this was appropriately discussed with the GP and pharmacy.