Norfolk Lodge

Updated 1 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Norfolk Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Norfolk Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection.

This inspection was unannounced. Inspection activity started on 11 May 2022 and ended on17 May 2022. We visited the home on both days.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 10 January 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

During our visits we used observations to help us understand the experience of people who could not talk with us. We spoke with four people who received the service and with six staff. These included two care workers, two senior care workers, the registered manager, and the regional manager. We also received feedback from three people’s relatives and four external health and social care professionals who have contact with the service.

We reviewed a range of records. These included sampling six people's care records, and two staff files in relation to recruitment checks. We also looked at a variety of records relating to the management of the service, including staff rotas and training records, meeting minutes, audits, quality assurance reports, and action plans.

Updated 1 July 2022

About the service

Norfolk Lodge is a residential care home providing personal care and accommodation to up to 30 older people. The home is in an 18th century building that has been extended and provides accommodation over two floors. At the time of our inspection there were 28 people using the service.

People’s experience of using this service and what we found

We saw positive interactions between people and staff. However, there were times when decisions staff made in the best interest of one person impacted negatively on others. On the whole staff respected people's privacy and dignity but there were occasions when private information was shared loudly in front of other people.

The provider had systems in place that helped ensure that staff delivered a service that met people's needs and kept them safe. Without exception, staff and relatives said there had been considerable improvement in the service since the current registered manager had taken up post. We received positive feedback from staff, relatives and external professionals about her influence on the service.

Lessons were learned when things went wrong, and actions to bring about improvement shared with staff. The provider's complaints procedure was available in the home. Complaints were investigated and feedback given that included any learning.

People felt safe and relatives trusted staff. Staff knew how to report any concerns to the registered manager, and externally to other organisations, such as the local authority. Staff were confident the registered manager would take any concerns seriously. Risks had been assessed and actions taken to reduce risk where possible. Medication was well managed and people received their prescribed medicines. Infection prevention and control was on the whole well managed. People were supported to eat and drink sufficient amounts. Staff referred people to external healthcare professionals and followed their guidance.

People’s care plans provided detailed guidance for staff to follow. Staff supported people to maintain contact with relatives. People’s opportunities for activities had increased in recent months and everyone had opportunities to go out of the home on local trips. Staff understood and fostered people’s particular areas of interest. Some people were occupied during our inspection with knitting, games, and or television. However, some people were just sitting unoccupied for long periods of time.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.