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Archived: Fernside Hall Care Home Requires improvement

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 October 2016

This inspection of Fernside Hall took place on 6 September 2016 and the visit was unannounced. Fernside Hall is registered to provide residential care for up to 24 older people. The accommodation is arranged over three floors and there is a passenger lift available. There are two lounges and a dining room on the ground floor and a kitchen/sitting area on the first floor. There are 20 single bedrooms, 18 of which have en-suite toilet facilities and two double bedrooms with en-suite facilities. At the time of our inspection there were 17 people using the service.

Our last inspection of Fernside Hall took place on 9 November 2015 and found breaches of regulations in regard to reporting of notifiable incidents, care records, reporting, analysis and actions following accidents and incidents, dignity and respect, audit and governance, recruitment, induction and training. We told the provider they needed to take action and we received an action plan. At this inspection we found improvements had been made with regard to these areas although the service needed to maintain and continue these improvements over a sustained period of time.

The manager of Fernside Hall at the time of the previous inspection had left the service. The manager at the time of our visit had been in employment at the service for approximately six months and had applied for registration with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe at the service and no-one we spoke with had concerns. Staff we spoke with understood how to keep people safe and what to do in an emergency situation. The service had safeguarding procedures and individual risk assessments were in place to keep people safe.

People we spoke with told us they liked living at Fernside Hall and were happy with the service. They told us staff were kind and caring and treated them with respect and good humour. A relative we spoke with confirmed this. We observed some compassionate and caring exchanges between staff and people living at the service and staff we spoke with knew people well.

We saw consent was requested wherever possible and people's individual preferences were taken into account.

Medicines were administered and generally managed safely although the service was in the process of altering the storage of medicines to ensure these were stored at the correct temperature.

Accidents and incidents were generally well recorded and appropriate procedures followed although the manager recognised this had not happened with one identified recent incident.

Staff were safely recruited to ensure they were of suitable character to work with vulnerable people. Staff received a range of training which was generally up to date and had opportunity to attend other service specific courses and professional development training. The manager was recommencing a programme of staff supervision and appraisals and was aware this was an area for improvement.

Overall, there were sufficient numbers of staff deployed although the service needed to review the numbers of staff deployed at peak times to ensure levels consistently allowed for safe care and support.

Care records were person centred and newer care records contained good, detailed information. Work was in progress to ensure all care records were of a good standard.

A range of activities was on offer, according to people's preferences and choices. People were consulted about what activities were of interest to them and the home employed an activities co-ordinator.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and acting within the legal framework of the Mental Cap

Inspection areas

Safe

Requires improvement

Updated 7 October 2016

The service was not always safe.

Medicines were managed and administered safely. However, the service had identified temperatures in the current storage areas for medicines was too high and was making alternative arrangements.

Staffing levels were generally appropriate although needed reviewing at peak times. Safe recruitment processes were in place.

Accidents and incident reporting had improved although further improvements were needed.

People and their relatives told us they felt safe in the service.

Effective

Good

Updated 7 October 2016

The service was effective.

The provider was working within the legal requirements of the Mental capacity Act 20015 (MCA) and Deprivation of Liberty Safeguards, (DoLS).

People's consent was sought wherever possible.

Staff training was up to date or booked and a training matrix was in place.

People enjoyed the food provided and were offered a choice of menu.

People had access to a variety of health care professionals.

Caring

Good

Updated 7 October 2016

The service was caring.

People were treated with kindness and compassion and privacy and dignity was respected.

Staff had a good knowledge of people's likes, dislikes and care needs.

People and relatives told us they were involved in the planning of their care although this was not formally documented.

Responsive

Good

Updated 7 October 2016

The service was responsive.

A wide range of activities were available, with individual and group work undertaken.

Care records were person centred and contained detailed information about people's care needs, likes and dislikes.

Care records were up to date and relevant to people's changing needs.

A complaints policy was in place although the service had not received any recent formal complaints.

Well-led

Requires improvement

Updated 7 October 2016

The service was well led, although improvements needed to be consistent and sustained before rating the domain higher than 'requires improvement'.

Systems were in place to manage, monitor and improve the quality of the service.

People were consulted about aspects of the service through questionnaires and resident meetings.

Comprehensive staff meetings took place regularly.