Norbury Court

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• 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

During our assessment of this key question, we found concerns around the management of people's medicines, the management of people's risk and infection control which resulted in a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found concerns relating to staffing which resulted in a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. People were not safeguarded from abuse and avoidable harm. The systems in place to learn from accidents and incidents required improvement.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they did not always feel able to raise concerns, and where they had, these had not always been addressed. Relatives told us they had made complaints about how they had seen staff treating people and missing personal items, and the manager’s response was very abrupt. One relative said, “When I reported it to the manager, they were very abrupt with me and talked down to me.” Two relatives told us they had made complaints about items going missing and provided details of the poor response. Comments included, “I have complained but nothing has happened” and “I have asked about it 3 times, but I get no response. I am really upset about it.” The registered manager had a process for monitoring and responding to complaints. However, there was no evidence these complaints had been investigated and responded to, with an apology given when needed.

Some staff told us they were reluctant to raise concerns because they felt vulnerable. One staff member said, “The manager does not listen to staff. Staff are leaving because the manager is not approachable.” This showed staff lacked confidence their issues would be addressed fairly or even taken seriously, which meant staff were reluctant to report their concerns.

The provider had not ensured there were effective systems in place to make sure managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing, and investigations.

There was evidence of involvement from other health care professionals in people’s care plans, and staff made referrals to ensure people’s health needs were met. However, people did not experience continuity of care. Relative’s comments included, “Sometimes they [people] don’t get a drink in the afternoon. It all depends on who is on shift. Several times I have gone to the tea trolley and the teapot is empty and [family member] hasn’t had a drink” and “My [family member] is always kept clean, but they [staff] know I come every day, some of them [people] aren’t clean.”

Staff told us people’s care plans were currently being transferred online from paper. Staff were not sure what records had been transferred over. This showed there was a risk inaccurate information could be shared or directions from health care professionals not being followed

We received mixed views from partners. Partners were aware the service was currently transferring from paper based documents onto PCS electronic care planning system. They told us some improvements had been made, but further improvement was still required.

Processes were in place to enable a smooth transition between services and to reduce the impact on people. However, the quality of people's care records and/or medication records required improvement to enable effective information sharing.

People spoken with did not share any concerns and felt safe. However, relatives raised concerns about the treatment of people by staff. One relative said, “I don’t trust any of the staff. I have seen them man handle one of the residents, grabbing and pushing them. I have also seen a resident shouted at.”

Staff spoken with were able to recognise signs of abuse and knew how to report such concerns. However, some staff did not always feel confident they could share concerns with the registered manager. This showed there was a risk concerns would not be reported appropriately.

The provider did not have effective oversight to identify and manage risks in relation to safeguarding people from abuse and improper treatment. Records showed staff had not always followed the provider’s policy for recording, reporting, and managing incidents and accidents. The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service was aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person. However, we found people’s capacity assessments had not always been completed or there was conflicting information within their assessments.

Some people’s risks had not been effectively assessed and measures in place to manage those risks.

Staff gave mixed feedback about the transition from paper to electronic care records. Staff gave us conflicting information on what records had been transferred over.

There were paper based and electronic care records, which meant information was difficult to find. It was unclear which care records had been transferred over to the electronic system. We observed 2 staff members using an underarm lift to transfer a person from a wheelchair to a sofa. This has the potential to harm people and goes against moving and assisting guidance. We observed the mealtime experience at the service. Some people were unable to eat as they required assistance, and there were not enough staff to support them. So, people had to wait until a staff member was available. One relative said, “There are 12-13 [people] that need feeding on this floor, and there should be 4 staff on, and sometimes there are only 3, so you can imagine how they have to wait to be fed.” There was confusion amongst agency staff who required support to eat. One person was being supported by staff, who left halfway through their meal and returned later. On three separate occasions, we saw staff standing over people while supporting them to eat and two staff members talking to each other while one person was being supported.

The provider had not ensured each person’s risks had been effectively assessed and measures in place to manage those risks. Some people had conflicting information within their risk assessments, which put them at risk of not being supported safely. People did not always have risk assessments and/or care plans in place for a specific health condition. Appropriate measures were not in place to ensure people had regular and appropriate pressure care regimes in place to reduce their risk of pressure sores or contribute to the healing or recovery of pressure areas. The provider did not have sufficient oversight of people's mealtime experiences to ensure people were appropriately supported. The systems and processes in place to ensure staff used safe moving and transfer techniques required improvement.

Relatives told us it was difficult to access the building due to staffing issues. One relative said, “It is really difficult getting in and out because there isn’t always someone [staff] around to let you in, especially at weekends when you can wait ages because there is no one on reception. I have complained but they just said it has to be like this.”

Emergency systems were not robust. Staff could not confirm how many people were resident on the day of our first visit and the emergency grab bag did not contain a list of people living at the service.

The service required a deep clean, and many areas were poorly maintained, making cleaning difficult, and storerooms were extremely untidy and disorganised. There was a hole in the ceiling in one room.

The systems in place to monitor the safety and upkeep of the premises required improvement. The provider had not ensured equipment used to deliver care was used properly or in good working order. For example, call bells were not in reach for people who could use them to call for assistance.

All the people and relatives spoken with raised concerns about the staffing at the service. One relative said, “Some of the staff that have been here a while are brilliant and know exactly what to do. Some of the newer ones need more training.”

Some staff spoken with raised concerns about the staffing levels and the training within the service. Staff comments included, “New staff they have an induction for 3 days, but they have never worked in care before. Sometimes language is a problem” and “They [staff] are rushed off their feet. They should have 4 staff and a nurse.”

During the inspection there was not an appropriate staffing level and skill mix to make sure people received consistently safe care that met their needs. Throughout our visit, staff were busy with care tasks. Staff had very few opportunities to spend any meaningful time with people or ensure their safety. There were times when people at risk of falls were left unattended for long periods of time by staff, and call bells were either not switched on or not within reach. This meant there was an increased risk of falls. During lunchtime, people who needed encouragement and prompting with their meals were not receiving this as staff were too busy.

Staffing levels did not always reflect the needs of people in the service. The registered manager used a dependency tool to assess the number of staff required. A dependency tool collates information about each person in receipt of care and support and calculates how many hours of staff support they need. However, the dependency tool did not account for the layout of the building or busy times of the day. Staff were provided with training around the needs of people including dementia and positive behaviour support. However, the training was not always effective in enabling staff to be competent in providing appropriate care. People living with dementia and people with behaviours that challenge did not have clear plans or guidance in place to guide staff about how best to support them. For example, staff had restrained a person who was experiencing heightened levels of anxiety. The provider had a recruitment procedure in place, so people were cared for by staff who had been assessed as safe to work with people.

People looked overall clean and tidy. However, a number of people had dirty fingernails. People were not protected as much as possible from the risk of infection because premises and equipment were not kept clean and hygienic.

The provider had not ensured there was enough domestic and laundry staff deployed at the service, so staff managed the control and prevention of infection well.

There were strong mal odours in areas of the service. The service required a deep clean and many areas were poorly maintained, making cleaning difficult, and storerooms were extremely untidy and disorganised. We saw personal protective equipment (PPE) was not stored appropriately. Some armchairs were dirty and in need of a deep clean. These practices increased the risk of cross infection. There was a substantial amount of dirty laundry stockpiled in the launderette posing a significant infection risk to both people using the service and staff. We found the process to make sure ‘dirty’ laundry was kept completely separated from ‘clean’ laundry was not possible due to the amount of dirty washing. This meant the risk of cross contamination was significantly increased. Appropriate laundry bags were not available to ensure soiled clothing and linen were hygienically transported and washed to prevent cross-contamination and infection exposure.

There was not an effective approach to assessing and managing the risk of infection, which is in line with current relevant national guidance. The provider had not ensured the equipment used to wash clothes and linen was in good working order and there were sufficient domestic and laundry staff deployed at the service. The provider had not ensured people were protected from the risk of infection. Following our visit, the provider took immediate action in response to our concerns.

When people were prescribed medicines to be taken ‘when required’ (PRN) or with a choice of dose the guidance to support the safe administration was not person-centred. This meant staff did not have enough information to tell them when someone may need the medicine or how much to give. Some people needed to be given their medicines covertly, hidden in food or drink. The information from a pharmacist to explain how to give each medicine safely was not always available. One person’s medicine was crushed against the manufacturer’s directions placing them at risk of having too much medicine at once. People were not always given their medicine as prescribed. One person was given a medicine for four days that was no longer prescribed for them. Three people had been given the wrong medicines. Other people were not given their medicines at the times they were prescribed for example antibiotics and medicines for Parkinson’s placing their health at risk of harm.

There was conflicting information as to whether staff administering medicines had been assessed as competent. After the inspection we were told staff had been assessed as competent. However. the competencies for a staff giving medicines via feeding tubes was still under review.

The processes in place for ensuring records were accurate and up to date was not always effective. The systems in place to ensure people received their time sensitive medication at the right time required improvement. The records made in the controlled drug register did not always follow legislation or good practice guidance. The system in place to ensure medicines were always stored safely was ineffective in practice. People’s PRN protocols required further guidance to ensure these were given at the times they needed them. When some PRN medicines were administered the effectiveness was not always assessed or it was not assessed and recorded in a timely manner. The processes in place to ensure transdermal patches were rotated safely in accordance with the manufacturers’ directions were not effective. The systems in place to ensure fluids were thickened safely was not effective. This placed people at risk of aspiration and the risk of chest infection or pneumonia. The processes in place to ensure covert medicines were administered safely was not effective. We found there was limited information recorded about how medicines should be given covertly for 6 service users.