Norbury Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvement was found at this assessment, and the provider was no longer in breach of this regulation.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Risks to people were not consistently used to learn and improve. For example, some audits were not yet embedded into practice to allow the provider to effectively mitigate risk or monitor for themes and trends.

We found the management team were open and transparent and wanted to drive improvement at the service. They were confident the new regional team alongside the new manager once recruited would provide greater oversight and monitoring of the service over the longer term.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s care records, although improved, did not always accurately reflect their needs or provide sufficient guidance to staff to allow them to support people safely or provide accurate or up to date information if shared with other professionals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, people’s care records although improved, did not always accurately reflect their needs or detail how the service was working within the principles of the mental capacity act.

Effective systems to provide robust oversight of accidents and incidents including safeguarding concerns, were still to be fully embedded. Records showed some notifications of incidents including safeguarding concerns had not always been reported to appropriate bodies as required. However, systems had recently been revised to address this and to ensure all parties received necessary information in a timely way.

Staff had completed safeguarding training and the provider’s safeguarding policy guided staff about different types of abuse and how to raise a concern to ensure people were protected. One staff told us, “People are safe. I have never seen anything of concern. If I did I would say something straight away.”

Overall people and their families told us they felt safe at Norbury Court. One relative commented, “Yes, [person] is safe. [Person] is eating properly and is looked after.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Effective systems to provide robust oversight of accidents and incidents including safeguarding concerns were not fully embedded.

Care records required more detail in some areas of support and for information to be updated across the home. For example, the information in dining areas had not been updated to reflect a change in need for 1 person at risk of choking. Where people needed to be hoisted, there was a lack of detail to guide staff about how to do this safely. Action was taken by the provider to address these issues.

Records of support completed by staff were now more regular and detailed. However, some records identified longer gaps between support than that advised in people’s care plans. For example, the care plan for 1 person identified that they should be repositioned 2 hourly but there were some occasions where the gap in the documentation was longer than this. We asked the provider to have greater oversight to ensure support was always completed at the frequency identified in the care plan.

Staff were aware of the risks associated with people’s care needs and could describe the support people needed to manage those risks. One staff told us they were now confident in their knowledge of people’s diets and could describe to us what diets people required.

The provider did not always detect and control potential risks in the care environment.

Some areas of the building were still tired and dated and in need of decoration. However, further planned works were due to take place including upgrade of bathrooms and decoration.

There were systems in place to monitor and improve the safety and upkeep of the premises. However, these had not always been completed at the expected frequency. This had been identified by the provider prior to our visit and revised systems had been implemented.

Information to be used in the event of a fire was not up to date. The provider agreed to update the resident list at the point of any change in occupancy.

Some relatives commented on access to the building being difficult. One relative told us, “The other day we went at around 11am and couldn’t get in the building.”

Although there were 2 lounge areas on each floor only 1 seemed to be utilised regularly. This caused the main lounge to appear overcrowded and impacted on visitors being able to talk privately with their relative or on activities taking place. The provider agreed to review how lounges were utilised and also told us of their plans to create a coffee lounge in the reception area which could also be used for activities.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff were not receiving supervision in line with the provider policy with records for supervision for staff for the second half of 2024 missing. Prior to our visit, action had already been taken to address the frequency of supervisions and appraisals. As a result, most staff had received supervision during January 2025. Staff were also more positive about the support they were now receiving. One staff member told us, “I have seen improvements over the last 12 months. I can see a greater interest in management for improving. They are trying to bring people closer and are listening to staff.”

Some staff training had not been completed in line with the providers training policy. An action plan and where appropriate risk assessments were in place to ensure there were always trained staff available to support people until all staff were fully trained.

Recruitment procedures were in place, so people were cared for by suitable staff who had been assessed as safe to work with people. However, some gaps in employment checks were noted for some staff recently employed and records of induction were not always present. The provider agreed to follow this up for those staff identified.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The home was generally clean but there were some areas that were worn and tired and not as easy to be kept clean. One relative told us “It seems clean. The building is tired, and the rooms are worn.” The provider was aware of these issues and had a further refurbishment plan underway.

Throughout the home, stocks of Personal Protective Equipment (PPE) were missing or running low making access to appropriate PPE difficult. The provider agreed to allocate this as a task to night staff to complete to ensure sufficient stocks were available for staff working during the day.

Items and equipment were being stored in sluice areas which presented a risk of cross infection. This was addressed immediately.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Mental capacity assessments for people receiving medication were not always completed and some front sheets in the medication folder required updating to reflect changes in how people received their medicine.

People were supported by staff who followed systems and processes to administer, record and store medicines safely. However, we found the competency assessment for 1 staff member was missing. This was actioned immediately and a new competency assessment completed.

A lockable trolley containing prescribed topical creams, was left unattended with the keys on top. The provider addressed this immediately.