Norton Lodge

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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

There was a lack of oversight regarding staff training, and there was no evidence that some staff working within the home had undertaken any training. Not all staff had received specific training required to carry out their roles effectively. The induction process for agency staff was poor. We spoke with one agency member of staff who had been working for over an hour without receiving any induction. There were no effective audits in place to ensure the service was operating safely. Audits that had been completed had not identified all the areas of concern found during this assessment. When concerns had been identified, there was no clear action plan in place to demonstrate that improvements were being made. Although people living within the service, relatives, and staff we spoke with told us the manager was approachable, there was concerns that issues raised were not acted upon. Staff were not frequently encouraged to provide feedback due to lack of meetings and supervision. Where staff had identified training needs, these were not actioned. There was no evidence of any learning from incidents and accidents. Not all incidents were reported to the relevant professional body for investigations to be carried out to ensure people were not at risk. Reflective practice was not encouraged. We identified staff were not deployed effectively, particularly during the night when staffing numbers were lower. This meant people were left without supervision for long periods of time. There was inconsistent and conflicting information shared between the management team, and there was lack of oversight from the provider to ensure the safe running of the home.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There appeared to be a divide between night and day staff, with a lack of communication. Whilst staff told us they could approach the manager, there was no evidence of this being recorded.

Agency staff did not receive a structured induction, which could impact their ability to deliver consistent care. There were also no regular staff meetings, limiting opportunities for open communication and collaboration among staff teams. Feedback between managers and staff was minimal, reducing the chance for constructive dialogue and improvement. There was also a lack of understanding and training around equality, further highlighting gaps in supporting an inclusive and informed workplace culture. Not all staff had received the training necessary to enable them to carry out their roles safely and to meet the needs of people living in the home. There was no oversight to identify gaps in learning.

There was no clear structure within the management team, and conflicting information was shared with us regarding staff roles and responsibilities, including the management team. There was no evidence of provider involvement. Agency staff did not receive an induction before commencing support, meaning we could not be assured all staff have the knowledge and skills required to support people safely.

Safe recruitment practices were not consistently implemented, raising concerns about the suitability of staff. There was a lack of effective audits to monitor and improve the quality of care and service delivery. There was limited evidence of regular supervision and appraisals to ensure staff felt appreciated and motivated. When a member of staff identified a learning need, this was not implemented.

Staff told us they could speak to the manager, and they were approachable; however, actions were not always completed as a result. Some staff were not aware of the whistleblowing policy.

Although, there was a whistleblowing policy in place, staff were not aware and did not have an understanding regarding whistle blowing and what it meant. Staff meetings were not consistently completed, which prevented information sharing with the staff team. Where concerns had been raised, they were not always addressed. For example, we identified a concern raised by a person living within Norton Lodge, however there were no actions to evidence this had been addressed. Staff were not provided with a staff room, which meant that information regarding whistleblowing and procedures for raising a concern were not clearly displayed.

Staff we spoke with told us they were not provided with a designated staff room, meaning they were not able to spend time away from their work environment. They had their lunch in communal areas within the home, which meant they were often disturbed by people living within the home, their relatives and other staff.

There were no effective systems in place to ensure all staff had the necessary training to enable them to support people safely. Additionally, there was no evidence staff were included in ways to drive the service forward and implement positive changes.

Staff we spoke with told us the manager was approachable and they felt able to raise concerns however, these were not always acted upon. Some staff told us that certain staff members did not work as part of a team, which added to the pressures they felt to do their jobs. One staff member we spoke with told us, “We don’t always get handover,” which meant we were not assured information was shared with all staff.

Staff received little support through regular supervisions, and poor communication hindered effective teamwork. There was a lack of oversight at the service, and systems to monitor the quality and safety of care were ineffective. Staff had not received sufficient training to allow them to support people effectively, and staff feedback on how to improve the service had not been sought. The deployment of staff was not effective, and we observed people at risk due to no staff supervision. A safe recruitment policy was in place; however, we found it was not always being followed. Risks to people had not always been identified, and therefore risk assessments were not in place when required to ensure risks could be mitigated.

People did not have access to the local community however, people told us they could see the GP when they wanted. One relative we spoke with told us, “My [person] is losing ability to swallow but staff are dealing with it.”

Staff told us they ensured people were supported to appointments when necessary, and any concerns they identified they would be reported to the senior member of care staff for them to action. The manager told us some concerns were not always shared or identified until after the incident had occurred.

We were unable to obtain evidence to score this category

The service had support from the GP who visited weekly. Safeguarding referrals were not always submitted when required. We identified incidents that required reporting to the Local Authority in line with the Care Act 2014, however these referrals had not been submitted. We also saw evidence where referrals had not been made to other professionals, despite a need being identified. We raised these concerns with the provider during our assessment, and the relevant referrals were made.

Staff told us the management team did not always act upon the issues they raised; however, we were told they were approachable.

There were no effective systems in place to ensure all staff had the necessary training to support people safely to meet the needs of the people living within the home. An action plan was in place in relation to the environment, and a refurbishment program was underway at the time of the assessment. However, risks involved in this process had not been identified, and actions were not taken to mitigate these risks. For example, fire doors not being compliant with health and safety regulations due to new flooring. The provider was in the early stages of implementing a new computer system, however staff had not received the training to enable them to record information effectively. This resulted in gaps within care records.