Norton Lees Hall & Lodge

Updated 16 February 2023

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 3 inspectors 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

Norton Lees Hall and 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. Norton Lees Hall and 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 all this information to plan our inspection.

During the inspection

We spoke with 8 people who used the service and 6 relatives about their experience of the care provided. We spoke with 6 members of staff including the registered manager, care workers and ancillary staff. We reviewed a range of records including 4 people’s care plans and multiple medication records. We looked at 2 staff files in relation to recruitment and supervision. We also reviewed a variety of management documents.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 16 February 2023

About the service

Norton Lees Hall and Lodge is a care home providing accommodation and personal care to older people. Some people were living with dementia. The service can accommodate up to 80 people in a purpose-built facility over two floors and four wings, each with a separate dining room and lounge. At the time of this inspection there were 53 people living at Norton Lees Hall and Lodge in three of the wings.

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

We carried out a tour of the home and identified concerns regarding infection prevention and control. Some areas required a deep clean and others required maintenance work to enable them to be cleaned effectively. Risks associated with people’s care were identified and staff knew how to mitigate risks. However, there was a lack of documentation to show risks were being managed in line with people’s needs. This was a records issue. People received their medicines as prescribed, although we identified some minor concerns in regard to maintaining appropriate records. We observed staff interacting with people and found they responded to people in a timely way.

Accidents and incidents were recorded and logged what action had been taken. However, there was no evidence to show that trends and patterns had been analysed to mitigate future risks. We looked at 4 recruitment files and found concerns with 2 files. We asked the registered manager to evidence what action had been taken to ensure suitable staff had been employed. We received supporting information, following our inspection, and asked for this during our inspection but this was not provided.

We reviewed the staff training record and found training required updating to ensure staff were trained in line with the providers policy.

We found people received a balanced diet, however choices were lacking. People had access to outside garden areas and signage was available to ensure people could navigate around the home.

Care plans were well written and clearly detailed people’s needs and follow up action when required but it was not clear from observations if care plans were followed. We have made a recommendation care plans are reviewed to ensure they reflect people’s current needs.

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.

The provider had a system in place to monitor the quality of the service. However, this was not always effective in identifying areas of improvement.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 27 August 2021 and this is the first inspection. The last rating for the service under the previous provider was rated good, published on 23 December 2020.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe and Well led sections of this full report.

Enforcement and Recommendations

We have identified breaches in relation to infection prevention and control and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.