Norton Lees Hall and Lodge

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.