Normanton Lodge Care 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

We identified 1 breach of the legal regulations under the well-led key question. The service was not always well-led. Systems and processes to oversee risk and drive improvement at the service were not always effective. Policies and procedures were not always followed. Staff reported a culture where not all felt able to speak up. Feedback was not always used to shape the service. The service worked in partnership with a range of professionals to help improve outcomes for people.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff reported that a positive culture was not always promoted within the staff team. Leaders were unaware of any specific issues staff had in relation to the culture at the service. They explained an open-door policy was in place for staff to report any concerns. During our assessment staff demonstrated a commitment to providing compassionate care. This was also reflected in the feedback from people and their relatives. One staff told us, “I love caring for other people, I get satisfaction from seeing people smile.”

We were not assured leaders acted to continually review and improve the culture of the organisation. It was not always clear how feedback from people, visitors and staff was used to shape the vision and strategy of the service. For example, results of a recent staff survey showed staff reported negatively in some areas. There was no review into the reasons why staff may have felt this way or action taken to improve on the feedback. A managers walk-around was completed daily, and the registered manager told us this was used to monitor the culture within the service. However, these documents did not consistently record what the management walk-around was reviewing. Therefore, we were not assured this check was effective in monitoring the culture or daily oversight of the service. A service user guide was shared with people which outlined the provider’s aims and commitments.

We received mixed feedback from staff regarding the leadership. Some said they felt supported to carry out their roles, others felt leaders were not always approachable and reported a lack of trust with management. This was due to concerns their feedback was not always kept confidential, or action would not be taken in response. The registered manager understood their regulatory responsibilities, for example notifying CQC of significant events. The registered manager felt supported in their role by the provider. An operations manager provided regular support to the service.

Processes and policies were not always followed and implemented by leaders. For example, the service did not always follow the provider’s policy in relation to falls as no suitable review or analysis was completed of falls. Leaders had received appropriate training to carry out their roles.

Not all staff were aware of the provider’s whistleblowing procedure. Some staff reported that they did not feel able to raise concerns with management due to concerns they would not be kept confidential, or action taken in response to their concerns.

Following our onsite assessment, the provider re-informed staff of the whistle-blowing procedure.

Some staff did not always feel empowered to raise concerns, or that they would be listened to. Leaders were able to provide specific examples of reasonable adjustments made for staff to support them at work.

Feedback on equality, diversity and inclusion (EDI) was gathered from staff, however where staff had reported concerns in this area there was no review or follow up to ensure policies relating to EDI were being adhered to. Policies and procedures in place that supported the fair and equitable treatment of staff who worked in the service.

Staff understood their roles, for example care staff, senior care staff and team leaders had different responsibilities. Staff knew how to access the provider’s policies to support them in their roles. Leaders were not always able to demonstrate an understanding of key risk within the service, or provide assurances on how improvements were being made.

Systems and processes to oversee risk and drive improvement at the service were not effective. This placed people at risk of harm. Audits completed did not always identify risks. For example, medicines audits did not identify the areas of improvement we found during our assessment such as ‘as required’ medicine protocols lacking personalised detail to support appropriate administration. In addition, information within audits was not always accurate. For example, a medicines audit stated no one was prescribed anti-psychotic medicines, however at least 1 person was. Where areas for improvement were identified, audits failed to take effective action to reduce or remove the risk. For example, a monthly manager’s audit noted ‘few areas need attention’ in regard to medicines. The audit did not identify clearly which areas needed attention, or who was responsible for addressing these issues. This meant we could not be assured audits were effectively reviewing risk. There were no audits completed of call bell response times, to ensure people’s needs were met quickly and in line with the provider’s policy and procedures. During our assessment the inspection team identified the call bell system had been muted. This meant we could not be fully assured people’s needs were being met.

Overall, people told us they were able to access support from a range of professionals or communities. For example, “Chiropodist, hairdresser, optician and any other profession needed can be accessed.” And “Any professionals can be easily accessed.” Some relatives felt communication on the feedback from the professionals was an area for improvement but were overall satisfied with how the service worked collaboratively with a range of professionals to improve people’s outcomes.

Staff understood the importance of engaging with professionals and valued their input when supporting people. For example, staff were working alongside relevant professionals to investigate a change in person’s needs buy clearly documenting changes in behaviour and feeding this back to help identify themes or triggers.

Stakeholders reported positive working relationships with the service and felt the service were receptive to feedback and acted proportionately to issues raised.

People’s care records clearly showed where relevant professional advice had been sought and provided. Systems were in place to communicate any recommendations.

Leaders were open to feedback and were engaged in the assessment process. Leaders were working with stakeholders to support improvement. They discussed current priorities and areas which had been addressed through their service improvement plan, this included strengthening the visibility of leadership at the Glen Care Unit.

The provider completed a quarterly audit of the service. This had identified areas for improvement and generated an action plan to address these areas. However, at the time of our assessment, there had not been sufficient progress against plans to improve the quality and safety of the service. We could not be assured that processes to ensure learning when things went wrong were effective. This was due to poor review and analysis of accidents and incidents.