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CQC report explained · a residential care home, run by Heera Care

Norwood House

15a Station Road, Gunness, Scunthorpe, DN15 8SU

Requires improvementpublished 11 October 2023, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Requires improvement
Some risks were not fully identified or recorded. Inspectors also found gaps in repositioning records and unclear records of medicines returned or disposed of.
Effective?
Good
This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
Caring?
Good
This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
Responsive?
Good
This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
Well-led?
Requires improvement
Records did not always reflect people's needs and care provided. Quality monitoring was in place, but actions identified through audits were not always recorded or revisited.
The latest report, explained

What inspectors found, October 2023

Norwood House rated Requires Improvement; inspectors found kind care and enough staff, but gaps in risk records, medicines records and quality monitoring.

This was an unannounced focused inspection on 13 September 2023. Inspectors looked at Safe and Well-led because of concerns about governance, medicines, staffing and risk management. They spoke with people, relatives, staff and a visiting professional, and checked care records, medicines records, staff files and the building.

The home had enough staff, safe recruitment and safeguarding training. People were treated with dignity, had access to healthcare and received support with diet and infection control. Staff and people described a generally positive and supportive atmosphere.

However, some risks were not fully recorded. Inspectors found gaps in records showing when one person was repositioned, and limited evidence that the home learned from incidents. Medicines disposal and return records were unclear. Food, fluid and repositioning records did not always match people's care plans, and audit actions were not always followed up.

Safe and Well-led were both rated Requires Improvement. The overall rating changed from Good at the previous inspection to Requires Improvement. The other three key questions were not inspected during this visit, so their previous ratings were carried forward.

What inspectors praised
  • Enough staff

    The manager adjusted staffing according to people's numbers and needs. Inspectors found staff were safely recruited and there were enough staff to keep people safe.

    The service had enough staff to keep people safe.from the report
  • Safeguarding

    Staff had safeguarding training and understood how to identify and report concerns. Required referrals were made to the local authority and followed up.

    Staff were trained to safeguard adults from abuse.from the report
  • Respectful care

    Inspectors saw staff respecting people's privacy and dignity. People were generally happy with the support they received.

    We observed interactions between people and staff that were positive.from the report
  • Supportive atmosphere

    The home was described as welcoming, warm and supportive. Staff morale was good and the culture was open and relaxed.

    Norwood House was welcoming, and the atmosphere was warm and supportive.from the report
What inspectors were concerned about
  • Incomplete risk records

    serious

    Not all risks linked to people's care needs were recorded. One person's repositioning records had gaps, creating a risk that the required support was not given often enough.

    A person's care plan identified them as requiring support to change their position in bed to reduce the risk of pressure areas developing.from the report
  • Medicines disposal records

    needs fixing

    The home had medicines policies, but there were no clear records showing medicines that had been returned or disposed of.

    However, there were no clear records available of medicines disposed of and returned.from the report
  • Care records did not always match needs

    needs fixing

    Food, fluid and repositioning charts did not always show the requirements set out in people's care plans. Inspectors asked the provider to improve its recording system.

    Records did not always evidence important information about people using the service.from the report
  • Audit actions not followed through

    needs fixing

    The home carried out audits, but actions identified through them were not always recorded or revisited. This limited assurance that improvements were completed.

    Where improvements to the service had been identified through quality auditing, action was not always recorded.from the report
  • Some areas needed refurbishment

    minor

    Inspectors were only somewhat assured about infection prevention because some areas needed refurbishment to allow more effective cleaning.

    Some areas of the care home required refurbishment to enable more effective cleaning.from the report
Questions to ask them, based on this report
  1. 01What has been done to make sure every person's risks are fully recorded and kept up to date?
  2. 02How do you now check and record repositioning support where this is part of a person's care plan?
  3. 03How are medicines that are returned or disposed of recorded, and who checks these records?
  4. 04How do you make sure food, fluid and repositioning charts match each person's care plan?
  5. 05Which actions from quality audits were outstanding, and how have you checked that they are now complete?

This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control under Safe; the other ratings carried over from the previous inspection. This explanation was written from the published report of 11 October 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Norwood House

5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.

  1. October 2023Requires improvementcurrent ratingdown from Good
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Norwood House

  2. June 2022Goodstayed Good
    Safe: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. December 2019Goodstayed Good
    Safe: GoodEffective: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. June 2017Goodup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. May 2016Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. September 2015

    Registered with the Care Quality Commission on 28 September 2015.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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