Archived: Ferns Nursing Home

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

This inspection was over two days. On the first day we visited there were not always enough staff on duty to meet people’s needs in a timely and appropriate way. Staff were not responding to call bells promptly which placed people at risk of not receiving care when they needed it.

Most people were being nursed in bed when they did not have a physical need or didn’t choose to stay in bed. A lot of these people required support with their meals and had to wait for assistance and their meals were going cold. Staff explained it took time to assist some people with meals as they could not be rushed.

People were not always regularly repositioned to ensure their comfort, and this could pose a risk to their skin integrity.

Risks to people were not being managed in relation to their nutrition and fluid intake.

People were placed at risk of cross infections because staff had poor infection control practices.

Although staff had received training regarding infection control, some staff were observed carrying soiled laundry around the home.

Cleaning was not taking place regularly around the home and in the kitchen.

The provider’s quality monitoring processes had not identified these concerns.

We raised these concerns at the end of the first day with the provider’s management team. They told us they would develop an action plan and work with the manager to implement it.

On the second day of the inspection, we observed improvements. People had been and were being assessed regarding having the opportunity to get up. During our visit nine people were enjoying time sat out in their rooms or in the communal areas.

People were having their call bells responded to promptly by staff and the management team. The provider was looking to add a device to the call bell system to be able to regularly audit call bell response times

Staff were seen wearing PPE and no poor practice was observed in relation to infection control. Cleaning schedules had been replaced and cleaning was taking place regularly.

People’s mealtime experience was improved. People were being shown sample plates of the menu, there were personalised individual menu cards on each person’s tray and new crockery and glasses had been purchased. We made a recommendation that the provider continue to review people’s mealtime experience in line with appropriate good practice guidance

Improvements had been made to improve the quality and variety of the food offered to people. A new head cook had been recruited and a new four-week menu was being trialled.

Staff were using the provider’s new monitoring charts, for food and fluid and repositioning. New improved guidance about people’s individual needs was made available to staff in different places. This ensured they had clear up to date information about people’s individual needs.

Care plans were being transferred to the provider’s new care plan paperwork. In the meantime, staff had access to the old care system as well to ensure they had information about people’s 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 manager and management team were working with the staff team to improve the culture at the home. People said they were supported by staff who were kind and respectful towards them. On the whole staff interactions with people were respectful. However, on the first day of our inspection staff were not always knocking on doors before they entered people’s rooms. Improvements were seen on the second day as all staff were seen to knock on people’s doors.

Staff monitored people's on-going health conditions and made sure they had access to the local GP's and other healthcare services as needed. Each week a healthcare team connected to the GP surgery visited the home and reviewed all of the people there and then met with the GP.

Improvements were needed in medicine management at the home. We made a recommendation that the provider ensure medicine management at the home was in line with the National Institute for Health and Care Excellence (NICE) guidance ‘Managing medicines in care homes.’

At the beginning of the inspection it was not clear staff were always recruited safely. The management team told us they had completed an audit of staff files and identified where there were gaps. By the end of the inspection we were assured recruitment checks had been completed.

There was not a robust induction programme in place to evidence new members of staff had completed an induction which ensured their competency for their role. A new induction workbook was implemented, and six staff had started using this induction workbook by the second day of the inspection.

People were cared for by competent staff who had received training to safely care for them.

All staff had received a supervision and told us they felt supported. One staff member told us how they had been supervising a small team and how it was effective.

The provider had taken action to ensure people were protected from risks associated with the building because improvements had been made in the testing and servicing of equipment.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 8 December 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements were being made, however the provider was still in breach of regulations.

This service has been in Special Measures since May 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate in well led or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced responsive inspection of this service on 6,7 and 13 October 2021. We identified three continuing breaches in relation to safe care and treatment, staffing and governance. We issued a requirement for regulations 12 and 18 and a warning notice for the breach of Regulation 17.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions, Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ferns Nursing Home our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Ferns Nursing Home is a nursing home providing personal and nursing care for up to 39 people. At the time of the inspection 26 people were living in the home.

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

Since our last inspection, the provider had made some improvements to the safety and quality of the service provided. However, further improvements were still needed to ensure compliance with their regulatory requirements.

Improvement were still required to the provider and manager’s quality assurance systems. Audits were not being undertaken in line with the provider’s quality assurance system and they had failed to identify all shortfalls identified through our inspection and the provider’s quality team walk arounds.

Not all staff had received training to ensure they were adequately skilled and trained to undertake their roles. Staff were not receiving supervision and an annual appraisal in line with the provider’s policy.

Staff and people were not assured there was enough staff in place. People and staff confirmed there were pressures at busy times throughout the day, which meant there were delays to people getting the help they needed.

Although staff were able to tell us about the care and support people received, people’s care plans were not always current and up to date. Where people had been identified as requiring specific support with their skin care, records did not confirm people were receiving this care in line with their individual needs.

Improvements were still required to ensure people had best interest decisions in place relating to their individual care needs.

Staff were not always wearing surgical masks in line with government guidance and laundry was not being stored to prevent to risk of cross contaminating to clean bedding and towels.

There had been a number of improvements made to the safety of the environment since our last inspection. Areas of improvement were still required including the covering of hot water pipes in two people’s bedrooms and outstanding actions on the provider’s fire risk assessment.

Following our last inspection some improvements had been made to ensure the service was being supported with a manager and a quality improvement team. The quality improvement team had started to identify shortfalls during their visits.

The service following our last inspection was working closely with a variety of health care professionals. People were having their needs reviewed and the manager was positive these reviews would improve people’s quality of life. Health care professionals felt people were safe.

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

Rating at last inspection

The last rating for this service was Inadequate (published in May 2021).

Why we inspected

We carried out an announced inspection of this service on 15, 25, 26 February 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when, to improve.

We undertook this focused inspection to check whether the Warning Notice’s we previously served in relation to Regulation 12, 13 and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We also followed up the on the breaches of legal requirements of Regulation 18, 19, 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. This report only covers our findings in relation to the Key Questions of Safe and Well Led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed following this targeted inspection and is now Requires Improvement.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ferns Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified three continuing breaches in relation to safe care and treatment, staffing and governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service has improved to ‘Requires improvement’ however the service remains in ‘special measures’ due to the Well-led domain being Inadequate. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Ferns Nursing Home is a nursing home providing personal and nursing care for up to 39 people. At the time of the inspection 35 people were living in the home.

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

The service was not well-led and managed; there were widespread and systemic failings across the service. There was a complete lack of oversight and governance in all areas. This put people's safety at significant risk. Shortfalls were not addressed, and the provider was not identifying ways to drive improvement.

Risks to people were not fully identified and risk guidance was not followed by staff. Records used to monitor peoples' health were not always completed or reviewed when there was a deterioration in peoples’ health conditions.

Risks relating to infection control were not being managed safely. COVID-19 risk assessments relating to staff, external staff, and people had not been undertaken in line with published guidance. The provider had failed to ensure external staff had received appropriate training in infection control and prevention, and testing for COVID-19.

Systems to monitor and administer medicines were not safe. Some additional information was required for medicines administered on a ‘when required’ basis.

People were not safeguarded from potential abuse and neglect. Incidents and accidents had not been effectively analysed and appropriate action taken to prevent reoccurrence. Notifiable incidents had not been reported to the local safeguarding authority or the CQC.

There were not enough suitably trained staff available to meet people’s needs. The plans in place to cover the service in the event of staff absence did not include arrangements should the management team be absent from work. At times, agency staff had been placed in charge of shifts with no management oversight. By the second day of inspection a peripatetic manager had been appointed and was managing the service.

The provider did not follow safe recruitment procedures. Staff did not receive a sufficient induction or suitable training to enable them to be skilled and competent in their role. Staff had not received appropriate supervision and appraisals.

Checks had not been completed to ensure the environment and equipment were clean and safe. Fire risk had not been managed effectively.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems in the service did not support this practice.

The provider had failed to seek and act on feedback from people, staff and relatives. Staff described a poor culture within the service; they told us they had experienced a difficult time with little support from the provider.

There were no effective systems in place to communicate with people and relatives. This was evidenced by complaints and our conversations with some relatives.

Relatives were not able to provide us with detailed feedback as they had been unable to visit the service, we received mixed feedback about the service.

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

Rating at last inspection

The last rating for this service was Good (published December 2018).

Why we inspected

We received information of concern about infection control and prevention measures at this service. The provider had an outbreak of COVID-19. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

We inspected and found there was a concern with infection control procedures and staffing and management arrangements, so we widened the scope of the inspection to become a focused inspection which included the key questions of Safe and Well-Led.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make significant improvement. Please see the safe and well led sections of this report.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ferns Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified eight breaches of regulation at this inspection in relation to safe care and treatment which includes medicines, infection control and risk assessment, premises and equipment, staffing, safe recruitment, consent, safeguarding people from abuse, governance, and failure to notify.

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

Special Measures:

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service.

This will usually lead to cancellation of their registration or to varying the conditions the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Ferns Nursing home provides nursing care with trained nurses available throughout the day and night. The home specialises in the care of older people. The majority of accommodation is on the ground floor with a small number of rooms on the first floor which can be accessed by a passenger lift. At the time of the inspection there were 36 people living at the home.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

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At this inspection we found the service remained Good.

Why the service is rated good

Since the last inspection a new manager and nominated individual had been appointed and registered with the Care Quality Commission.

The new registered manager had begun to implement changes and improvements to the home and the care people received. People and visitors felt the registered manager and staff were very approachable and keen to listen to their views and ideas.

People felt safe at the home and with the staff who supported them. There were systems in place to minimise risks to people and staff knew how to report concerns. The environment was regularly audited and well maintained which meant people lived in a pleasant and safe environment.

People received effective care and support because their health was monitored by trained nurses who made sure they received prompt treatment to meet their individual needs. All staff received training to ensure they were practising in accordance with up to date best practice guidance and legislation.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were cared for by staff who were kind and friendly. Comments about staff included, “They chat with me quite pleasantly, if I want anything, they will do it” and “They make me feel comfortable, if I want something in particular, they run around for it”

Staff were responsive to people’s wishes and adapted care and support to meet people’s changing needs. People felt able to follow their own routines. One person told us, “It’s quite relaxed. You can do what you want to.”

People had access to a range of social activities which were inclusive of everyone regardless of their culture, background or abilities. Where people choose not to join in their privacy and independence were respected.

Further information is in the detailed findings below

At the last inspection, the service was rated Good.

At this inspection we found the service remained Good

Why the service is rated Good.

People felt safe at the home and with the staff who supported them. One person told us, “It’s a comfort to know there is always someone here. That makes you feel safe.” The provider had appropriate systems to make sure staff were thoroughly checked before they began work and knew how to recognise and report any suspicions of abuse. People received their medicines safely from registered nurses.

People received food and drinks which met their dietary needs and took account of their preferences. One person told us, “Food is always very nice.” People’s healthcare needs were monitored and the home supported people to access healthcare professionals according to their individual needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were cared for by staff who were kind, caring and patient. People’s privacy and dignity was respected and personal care was provided in accordance with people’s wishes. People or their representatives were fully involved in decisions about their care and treatment including the care they would like to receive at the end of their lives.

Care and support was personalised to people’s individual needs and wishes. One person said, “They get used to how you like things done and they always oblige.” People had access to social and mental stimulation through group activities, trips out and one to one support. The provider had a complaints procedure which made sure all complaints were investigated and action was taken to address any identified shortfalls in the care provided.

People benefitted from a management team who were open and approachable and had systems in place to seek people’s views and ensure ongoing improvements to the service. The home was well maintained to ensure the safety and comfort of people. Staff morale was good which helped to create a happy and relaxed atmosphere for people to live in.

Further information is in the detailed findings below.

Is the service safe?

Some people were at risk of unsafe care and treatment. People were not supported to move safely. A compliance action has been set for this and the provider must tell us how they plan to improve.

People who used the service were not always protected from the risk of abuse. The provider had not responded to an allegation of abuse and had failed to report this, and other incidents of concerns to the appropriate authorities. A compliance action has been set for this and the provider must tell us how they plan to improve.

Some people's care records and daily care charts were inaccurate or incomplete. For example, there was information in people's records about creams they required to protect their skin. The forms used did not contain enough information about where and when creams were applied. A compliance action has been set for this and the provider must tell us how they plan to improve.

Recruitment processes used to select and employ workers at the home were inconsistent. Appropriate checks were not always carried out on new staff before they started work. This meant that the home was not following safe procedures to ensure that staff were suitable to work with vulnerable adults. A compliance action has been set for this and the provider must tell us how they plan to improve.

There were not enough qualified, skilled and experienced staff to meet people's needs. People, and their relatives had expressed concerns about staffing in the home. Staffing arrangements did not ensure continuity of care for people who used the service. A compliance action has been set for this and the provider must tell us how they plan to improve.

Staff received inconsistent support and training and some staff did not receive appropriate professional development. Staff had not received regular and consistent supervision and appraisals were overdue. This meant that people who used the service were cared for by staff who were not fully supported to deliver care and treatment safely and to an appropriate standard. A compliance action has been set for this and the provider must tell us how they plan to improve.

Is the service caring?

During our inspection, we observed that people were treated with dignity, consideration and respect. However, some people who used the service expressed concern about night staff who worked in the home. For example, one person told us that night staff were less tolerant than day staff and some night staff did not speak with people at all. Another person told us that a member of night staff had been abrupt with them for using their call bell and had caused another resident to cry.

Is the service responsive?

The provider did not always respond appropriately or promptly to complaints. While one complaint had been addressed and responded to, others had not been fully addressed. For example, one complaint was not investigated promptly. Concerns raised by people and relatives in 2013 were similar, and in some cases the same, as in 2014, with insufficient actions or change. This meant that people's concerns were not always effectively or fully addressed. A compliance action has been set for this and the provider must tell us how they plan to improve.

Is the service well-led?

There were systems in place to check the quality of the service. The views of people and their representatives were sought and relatives told us that if they had any concerns, they would approach staff. However, the home did not have suitable processes to identify, monitor, assess and manage risks to the health, safety and welfare of people who use the service and others. A compliance action has been set for this and the provider must tell us how they plan to improve.

The Care Quality Commission (CQC) requires providers to notify us of some incidents and events that occur in the home. Both during and following our inspection, we learned of several incidents that had not been reported to the CQC. The provider's failure to report incidents meant we had not been able to check they had taken appropriate action and did not promote a multi-agency response to concerns.

One person we spoke with told us 'You get everything you need here, the staff are all very helpful and you can do things in your own time'.

One person told us they were very happy living in the home and that the staff 'they always tell you what's going on'. Another person told us that the staff always asked 'would you like to?' and respected their choices.

We saw that staff used signals and gestures for people unable to respond verbally and this appeared to reflect their knowledge of people and their relationships with them. We found a system of individual care planning in place which was regularly reviewed for each person.

The service worked well with other agencies to meet care standards. We found evidence that staff were trained to understand their role in safe use of medicines. We spoke with six staff members who expressed a highly positive commitment towards the people who used the service and to the home.

We observed an open culture of feedback from relatives and encouraged suggestions from staff about improvements. There were systems to identify and manage risks relating to the service and for monitoring and checking quality and safety in the home.