Norbury Court

On this page

• 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

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Not enough improvement was found at this assessment, and the provider remained in breach of this regulation.

This service scored 54 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. However, although staff reported improvements, recurrent changes to the senior team was affecting team morale and their awareness of the future vision of the service. One staff told us, “We have gone round in circles. All managers want things done differently. There has been no consistency.”

Leaders told us they were committed to ensuring staff felt supported, listened to and that they promoted a positive culture. At the time of our assessment the provider was recruiting to the vacant manager post and support was being provided by the senior regional team with increased involvement from the provider.

Staff told us they felt more supported and were now happier in their roles. However, numerous management changes were impacting on service delivery and staff wellbeing, with staff uncertain about further changes with the recruitment of another manager.

The provider was keen to reestablish a positive culture where people felt they could speak up and their voice would be heard. Feedback had not been actively sought and both people and relatives were unsure who to go to should they have an issue. One relative told us, “I don’t know the manager. There’s been a lot of changes. No questionnaires or family meetings.”

The provider was in the process of reviewing systems to facilitate better communication and involvement for people and relatives in their care with dates for meetings being planned.

The provider told us they valued diversity in their workforce. They told us they worked towards an inclusive and fair culture by improving equality and equity for people who worked for them and adjustments made where possible to support staff with their personal circumstances. Staff told us they were now feeling more supported and felt things were improving but were unsure whether this would change with another new manager. Supervisions for 2024 had not met the frequency identified in the provider policy or improved in frequency since our last visit where we identified his as an area to improve. A revised system had been implemented prior to this visit and most staff had received a supervision or appraisal in January 2025. Processes for support and seeking feedback from staff needed to be sustained and fully embedded in to practice.

The provider failed to ensure that effective governance and audit systems were being completed consistently. Audits had not always been completed and some areas identified in previous visits had not been fully addressed.

The lack of effective monitoring systems meant issues may not be identified and lessons may not be learnt when things went wrong. This evidenced systems and processes of governance were not yet robust or effective to ensure concerns were identified and actioned in a timely way.

The provider had taken action to address these issues and had increased senior on-site presence whilst the vacant manager position was filled. However, consideration should be given to continued provider oversight following the new manager starting in post to ensure systems are embedded and improvements implemented and sustained and to show consistent improvement.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Partners were mainly positive of their experience of working with Norbury Court.

The senior team had a strong commitment to improving the service and were open to suggestions for improvement, recognising the importance of joint working with partner agencies. One partner told us, “I personally think the working partnership is positive and I don’t have any concerns.”

Systems in place at the time of assessment did not provide sufficient or consistent oversight of the service. This reduced the ability of the provider to review information and complete lessons learned, presenting a potential risk to people.

We found repeated changes within the senior team had impacted on progress and the ability of the provider to focus on continuous learning, improvement and innovation.

Active gathering of feedback from people, relatives and staff had not taken place to inform and improve service delivery.

Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and had already identified and acted on key areas of improvement. Evidence was provided during and following the assessment of action taken, and assurance given by the provider of their commitment to address issues and sustain progress over the longer term, and to ensure improved outcomes for people.