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 the provider had not taken enough action to meet breaches in legal requirements we found at the last assessment of the service. Governance systems had improved since our last inspection. However, they required further embedding into practice to ensure their efficacy. Management of medicines, the quality of people’s care records, risk management and infection control required further improvement. These issues meant the provider continued to be in breach of regulation 17 of the HSCA 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Staff told us they felt supported in their roles, able to raise concerns and that the service had improved since the new senior team were in post.

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.

The manager and deputy manager told us they were committed to addressing outstanding actions, sustaining improvements made and continuing to develop the quality and safety of the service. However, our assessment found elements of care still did not meet expected standards. Staff told us they felt supported in their roles, able to raise concerns and that the service had improved since the new senior team were in post.

Since our last inspection governance systems and processes had improved. However, they required further work and embedding in to practice to ensure they drive improvements within the service. Quality and safety audit systems were not always effective and did not always identify concerns found during the inspection. 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, medicine management, infection control and assessing and monitoring risks to people's safety. The provider acknowledged the service still had some concerns and was taking action to address them. Concerns noted on our visits were actioned immediately by the provider. Confidence in the new team was growing and staff felt confident in being able to speak up and raise concerns if needed.

The leadership team were committed to ensuring the service improved and had taken action to address concerns we found on this assessment. However, our assessment found elements of care still did not meet expected standards. Systems to seek feedback from people, relatives and staff, were being reviewed and extended to inform and improve the quality of care people received.

We found the systems in place to ensure improvements were being made were still not fully effective. This was evidenced by a number of concerns found at the last assessment that were still in progress or had not yet been addressed. Further action was required to ensure effective systems were in place to drive learning and improvement at the home. The management team understood their duty of candour, to be open and honest when things went wrong.