Norbury Court

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• 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

During our assessment of this key question, we found concerns around the culture, the governance and leadership of the service which resulted in a continued breach of Regulation 17 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. The service did not have a positive culture that was person-centred, open, inclusive and empowering. People were not supported to have maximum choice and control of their lives because choice was not always actively promoted. The provider did not have sufficient oversight to monitor the quality and safety of the service and to ensure there was effective leadership in place. The service did not have an effective quality assurance system to ensure people received safe care which was person-centred. The provider had failed to learn lessons and take action to improve the service since our last inspection.

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.

Staff shared concerns about the management of the service. Staff did not feel listened to and that their concerns were acted on by the registered manager. This was reflected in the feedback from relatives.

The provider did not have sufficient oversight to ensure the service had a positive culture that was person-centred, open, inclusive, and empowering and there was effective leadership in place.

There was not an inclusive culture at the service. Staff and relatives raised concerns about the leadership of the service.

Staff and relative’s feedback showed the registered manager had not promoted a listening culture that promoted trust and was focused on learning and improvement. The provider did not have sufficient oversight to ensure they were alerted to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff.

Staff knew about whistleblowing procedures. This meant staff were aware of how to report any unsafe practice. However, some staff felt their voice would not be listened to and valued.

The provider had a complaint’s process in place. However, relatives told us concerns were always taken seriously, explored thoroughly, and responded to in a suitable time. Relatives told us they had not been invited to attend any resident and relative’s meetings or asked to fill in survey. This showed the systems in place to actively seek relative’s views required improvement. The provider had not ensured there was a culture of speaking up where staff could actively raise concerns and those who did were supported, without fear of detriment.

Staff said they did not feel they were treated fairly, or their voice was heard.

The provider did not have sufficient oversight to ensure equality and diversity was promoted, and the causes of any workforce inequality were identified, and action was taken to address these.

Staff could not confirm how many people were resident on the day of the inspection and the emergency grab bag did not contain of list of people residing at the service. Staff told us there were not sufficient staff to enable them to deliver person-centred care. There was only 1 nurse on duty on our arrival when there should have been 2. There was no management available to speak with. The deputy manager had been working the night before our first visit to cover the absence of a nurse and the registered manager was on annual leave.

The provider failed to implement and operate effective risk management systems and to assess, monitor, and mitigate risks to people. We found various shortfalls relating to, for example, medicine management, infection control, recruitment, and assessing and monitoring risks to people's safety. People’s basic rights were not being respected, and there was a lack of effective management and leadership at the service. Quality audits were in place, although these lacked specific detail and did not always identify the action taken to follow up on discrepancies or missed information. For example, infection control audits were evident, but these did not identify the shortfalls we found during the inspection. This placed people at risk of harm.

Staff gave us conflicting information on what records had been transferred over to the electronic system. This showed there was a risk inaccurate information would be shared with other professionals or staff not following guidance provided by healthcare professionals.

The provider had worked alongside the local authority to improve care at the home following the last inspection. However, these improvements had not been sustained and embedded into the quality of the service.

In people’s records we found evidence of involvement from other professionals such as doctors, optician, tissue viability nurses and speech and language practitioners. However, the quality of people's care records and risk management required improvement to enable effective information sharing between the service and healthcare professionals.

Some staff told us they were reluctant to raise concerns because they felt vulnerable due to the management of the service. This showed there was a risk concerns would not be reported appropriately.

Lessons were not always learnt when things went wrong. Concerns identified at the last inspection had not always been addressed and incidents were not always investigated. The systems in place to make sure managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing, and investigations required improvement. The provider had not ensured there were effective processes in place to ensure learning happens when things go wrong and from examples of good practice.