Fernihurst Nursing Home

Fernihurst Nursing Home was providing personal and nursing care to 43 people aged 65 and over at the time of the inspection. The service can support up to 50 people. The building is purpose built over three floors with lounges on each floor. There is an accessible garden with different seating areas and raised flower beds.

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

There was a calm and welcoming atmosphere throughout the home with good relationships amongst people, staff and visitors. A relative said, “During a very difficult year for all of us the staff have been very understanding and helped me and our family cope.”

People said they felt safe; they received their medicines on time. A person said, “I am very happy . I feel safe.” People were protected from abuse because staff understood their safeguarding responsibilities. The management team took this role seriously and liaised with other health and social care professionals to protect people.

Staffing levels delivered responsive support to people. Our discussions with the management team and staff demonstrated their empathy towards the people using the service; they recognised people's emotional needs. Staff were attentive, whatever their role in the home, this was because they worked as a team to promote people's well-being. A relative said, “We have been extremely lucky that there was space to take my Mum, the care and love all the staff show her and my Dad has been outstanding, I don't have to worry about my Mum, which is a huge relief for me.”

Positive, meaningful relationships had been developed between staff, people and their families. People were at ease in their surroundings; a person said, “I call this home.” A relative said communication was so important to them and described the staff as “amazing” at fulfilling this role. The service respected and recognised people's life experiences and their values, so people were supported to participate in events important to them.

There was a stable staff group; care staff were kept up to date with changes in people's health and spoke respectfully about the people they supported. They understood how they contributed to both people's physical health and mental wellbeing.

The staff structure provided clear lines of accountability and responsibility, which helped ensure staff at the right level made decisions about the care and well-being of people. The management team regularly spent time on the floor to ensure they kept in touch with staff and people living at the home. A staff member said, “Good company to work for with good managers and a good bunch of people work here.”

Recruited care staff suited the caring values of the service and recognised the importance of team work to provide consistent and safe care. The home was well maintained, clean, and staff understood the importance of good infection control.

Complaints were well managed. Visitors said they were kept informed and praised the standard of communication about changes to the health of their relatives. A relative said, “The staff have kept us updated with any changes…I would recommend them to anybody. I would find it hard to find how they could improve.”

The registered manager and care staff worked well with community health professionals to ensure people received effective care. Referrals were appropriately made to health care services when people's needs changed. People's care needs were regularly reviewed. Risk assessments identified when people could be at risk. They covered people's physical and mental health needs and the environment they lived in.

The service was well-led. There were good systems in place which enabled the registered manager and the providers to monitor the quality of care. For example, through regular reviews, surveys, meetings and observations of staff practice. Feedback from people using the service, relatives and quality assurance records showed this approach had been effective.

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.

Rating at last inspection and update The last rating for this service was requires improvement (published 4 July 2019). There were no breaches of regulation. At this inspection we found improvements had been made.

Why we inspected

This was a planned inspection based on the previous rating.

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.

We undertook this focused inspection to check they had made improvements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led. 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. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fernihurst Nursing Home on our website at www.cqc.org.uk.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection. For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: At the last inspection the service was rated as ‘Requires improvement’ The report for this inspection was published in November 2018.

Enforcement During the last inspection we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk from harm because the provider ’s quality assurance system had not identified issues at the service which put the health, safety and welfare of people using the service at risk. This included unsafe management of medicines, poor staff response times to call bells with monitoring checks not always taking place and protecting people from abuse.

Why we inspected: This was a scheduled comprehensive inspection based on the previous rating of ‘Requires improvement’.

People’s experience of using this service:

People and relatives said they felt safe at the home. Comments included, “I do feel very secure here. I have never felt less than safe.” People and relatives were positive about the caring nature of the staff. Comments included, “They’re beautiful people…they are marvellous to me.” Staff were very respectful to people, they showed genuine compassion and treated them with kindness.

Some people were observed on the first day of the inspection, unshaven, with poor oral care and looking a little unkempt. Care plans did not give staff clear guidance regarding people’s personal care needs and there was not any clear oversight by the management team to ensure people received their required personal care. During the inspection action was taken to add oral care needs to people’s care plans with plans to review all care plans. We were reassured by the management team that they would monitor and ensure people were receiving appropriate personal care to meet their needs.

People were supported by staff who continued to be aware of the signs of abuse and reported concerns internally. There had been significant improvements in the timeliness of the management team reporting concerns to the local authority safeguarding team and putting in place measures to protect people. Medicines were administered safely, and people received their medicines in the way prescribed for them.

People’ individual risks were assessed and managed. Staff knew their responsibilities for reporting accidents, incidents or concerns and these were reviewed. The service had a recruitment and selection process that helped reduce the risk of unsuitable staff supporting people. Reassurances were given at the inspection that all agency staff would have their identity checked and received an induction.

The provider had quality assurance processes in place. Regular audits were undertaken, these included, information about people's weights, risk management, pressure damage, medicine errors, accidents and incidents, premises audit, care plan audit and staff feedback. Improvements were needed to ensure staff identified health and safety risks at the home and would take appropriate action.

The management team had produced a service improvement action plan (SIAP) setting out what actions they needed to undertake. They had been working with the local authority quality assurance and improvement team. This had been effective in ensuring the standard of care provided to people had improved.

Staff were trained and were supervised, supported and clear about what was expected of them. They were very happy about the level of training and support they received and showed competence when supporting people.

There were sufficient staff on duty to meet people’s needs and keep them safe. The manager monitored call bell response times to ensure people received support in a timely way.

The provider recognised the importance of social activities. Staff encouraged people to engage in meaningful activity to aid both their physical and emotional well-being.

People’s nutritional needs were met. Staff had a good relationship with local health professionals and people had a weekly GP visit. People’s, relatives’ and staff views were sought, and opportunities taken to improve the service.

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 and relatives knew how to make a complaint if necessary.

The provider was in the process of a redecoration and refurbishment program at the home. They had an infection control policy that was in line with best practice guidance. Personal protective equipment (PPE’s) such as gloves and aprons were around the home for staff to use.

Follow up: We will continue to monitor the service to ensure that people continue to receive safe, compassionate, high quality care.

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

Fernihurst Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. They

provide care and accommodation for up to 50 people. The majority of people at this service live with dementia or have mental health needs. The service is a purpose-built care home providing accommodation over three floors, with two lifts between floors and with communal facilities on each floor. There were 46 people using the service on the first day of our inspection.

There was a new registered manager who registered with the Care Quality Commission (CQC) in February 2018. They had previously worked as the deputy manager at the home. A registered manager is a person who has registered with CQC 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.

Staff and relatives said at times the staff levels at the service were too low. The provider had a system in place to assess people’s dependency to determine the number of staff and range of skills required in order to meet people’s needs. During the inspection people were wandering in and out of other’s rooms. This was normalised behaviour at the home and action was not being taken by staff to try and prevent this. The provider increased the staff levels during the inspection.

People were placed at risk because of poor staff response times to call bells. This posed a risk to people because when pressure mats were activated setting off an alarm by people wandering into other’s rooms. There was confusion at the service about which people required regular checks. The provider took action to address this concern.

There was not a robust system at the service to ascertain if staff were responding to call bells promptly. During the inspection process the call bell system was serviced to ensure it was working correctly. The management team held a staff meeting and made staff aware of concerns found at the inspection which included call bell response times and that call bells would be monitored.

Staff did not always have the information they needed to support people with complex behavioural needs receiving emergency one to one support. Staff were not ensuring they stayed with people requiring one to one support at all times. This posed a risk to the person, others and staff. The registered manager and regional manager took action regarding these concerns.

The provider was not always ensuring people were protected against the risk of abuse. There had been a delay on two occasions of the management team informing the local authority safeguarding team of safeguarding concerns. This placed people at risk of further abuse. The management team were working with the local authority safeguarding teams regarding these concerns and to mitigate further risks.

Improvements were needed to the way people’s medicines were managed and recorded. Medicines were not always administered or recorded correctly. Some people’s medicine administration records (MARs) had one or more gaps for regularly prescribed medicines where it was not clear of a dose had been given or not. It was not possible to be sure if peoples’ external products were being applied in the way prescribed for them. Medicines had not been re-ordered in a timely way to prevent people’s doses being missed.

The provider had quality assurance processes in place and a service improvement plan (SIP) to continually develop the service. We identified areas of concern during the inspection which had not been identified by the provider’s quality assurance systems. During the inspection the provider took action to resolve some areas of concern and added further actions to the SIP.

Recruitment procedures were thorough and all necessary checks were made before new staff commenced employment. New staff had received an induction when they started working at the service. There was a system to ensure staff received training to ensure they had the right skills and knowledge to meet people’s needs. Supervisions and appraisals had been completed. It was not always clear that the registered nurses at the home always recognised their roles and responsibilities particularly in relation to staff allocation re monitoring checks. The registered manager was working with them through supervisions to ensure they knew what was expected of them.

Staff recorded accidents promptly in the accident book and the actions they had taken at the time. However, staff were not recording accidents and incidents where they had been placed at risk or injured. Therefore, there was no oversight monitoring of these incidents by the management team to support staff and put in place measures to prevent further incidents. The provider took action regarding this concern.

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. The registered manager and nurses demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. They understood where people lacked capacity, a mental capacity assessment needed to be completed with best interest decisions made in line with the MCA. They had submitted applications where required to the local authority Deprivation of Liberties Safeguarding team (DoLS) to deprive people of their liberties.

People were supported to have regular appointments with their GP, dentist, optician, chiropodist and other specialists. Each week a GP undertakes a visit to the service to review their patients. Health professionals said staff followed their guidance and called them promptly.

The provider recognised the importance of social activities and ensured people’s social needs were being met. There was a designated activity person supporting people with activities. They were very passionate about delivering activities and were always looking to further develop the activities at the home.

Staff knew people well and were aware of people’s needs and supported them as individuals. Care plans were in place for people’s every day personal needs which guided staff how to support people. However, there were no care plans to meet people’s specific health needs and dealing with behaviour that challenges. The regional manager was aware of this and was working to have them implemented on the computer system. Care plans and risk assessments were reviewed on a regular basis and when a change in their needs was identified. The registered manager and staff were committed to ensuring people experienced end of life care in an individualised and dignified way.

Staff were kind, friendly and caring towards people, they treated people with respect and dignity. People were supported to eat and drink sufficient amounts to maintain their health. People said they liked the food provided.

People and those important to them had opportunities to feedback their views about the home and quality of the service they received. The registered manager held regular meetings with staff and actively sought their views. The premises and equipment were on the whole managed to keep people safe. Except for the call bell system which was serviced during the inspection.

The provider is required by law to send CQC notifications about important events at the service. For example, deaths, serious injuries or safeguarding concerns. We received notifications as required from the provider.

We found three breaches of regulation. You can see what action we told the provider to take at the back of the full version of this report.

At the last inspection in July 2015, the service was rated Good. At this inspection we found the service remained Good.

There was a registered manager. 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.

Relatives and staff gave us positive feedback about the management team. They said they were open, friendly and welcoming. They were happy to approach them if they had a concern and were confident that actions would be taken if required. The registered manager and deputy manager were very visible at the service and had an open door policy. They promoted a strong, caring and supportive approach to staff and put a high emphasis on staff training and increasing their knowledge.

There were sufficient numbers of suitable staff to keep people safe and meet their needs. The registered manager was using two dependency tools to assess they had sufficient staff and that they were deployed in the right areas of the home.

The staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (2005) (MCA). Where people lacked capacity, mental capacity assessments were completed and best interest decisions made in line with the MCA.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. They had made appropriate applications for people they had assessed that required to be deprived of their liberty to the local authority DoLS team.

People were supported by staff who had the required recruitment checks in place and were trained and had the skills and knowledge to meet their needs. Staff had received a full induction and were knowledgeable about the signs of abuse and how to report concerns.

Improvements were made during the inspection to ensure monitoring checks were regularly made to people in their rooms and recorded. Systems were also put in place so the nurses and management team formally monitored that the monitoring forms were being completed.

People were supported to maintain a balanced diet. We discussed that not all people had drinks available in their rooms. Action was taken to address this. People and visitors were positive about the food at the service.

People received their prescribed medicines on time and in a safe way. Visitors said staff treated their relative with dignity and respect at all times in a caring and compassionate way.

People were supported to follow their interests and take part in social activities. A designated activities coordinator was employed by the provider. They ensured each person at the service had the opportunity to take part in activities and social events which were of an interest to them.

Risk assessments were undertaken for people to ensure their health needs were identified. Care plans reflected people’s needs and gave staff clear guidance about how to support them safely. Care plans were person centred and people where able, and their families had been involved in their development. Staff were very good at ensuring people where able were involved in making decisions and planning their own care on a day to day basis. People were referred promptly to health care services when required and received on-going healthcare support.

The premises were well managed to keep people safe. There were emergency plans in place to

protect people in the event of a fire or emergency.

The provider had a quality monitoring system at the service. The provider actively sought the views of people, their relatives and staff through staff and residents meetings, surveys and questionnaires to continuously improve the service. There was a complaints procedure in place. There had been two formal complaints in the last 12 months which had been responded to in line with the provider’s policy.

Further information is in the detailed findings in the report.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 49 people living at Fernihurst Nursing Home.

The summary is based on our observations during the inspection. We spoke with six people using the service, the acting manager, deputy manager and nine staff supporting them. In addition we spoke to five agency staff working at the home supporting people who required one to one support.

We also spoke to four visitors at the home and a doctor who visited the home most weeks to undertake a review of their patients. We asked their views about the care people received.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The acting manager ensured there were staff on duty with the appropriate qualifications, skills and experience required to ensure people's needs were met. People were supported by staff who had received appropriate training in the skills required to perform their roles.

The acting manager understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty safeguards (DoLS). The manager had made an application to the local safeguarding deprivation of liberties team. This meant that the home had needed to deprive somebody living at the home of their liberties. We saw that the home had acted in line with Deprivation of Liberty Safeguards legislation (DoLS). This legislation protects people's rights when they are unable to make decisions about their own welfare.

A visiting GP told us that he had seen improvements at the home, he felt well informed regarding changes to his patients and that the home had followed guidance and instructions that he had given.

The home had suitable arrangements in place to reduce the risks of people receiving inadequate nutrition or becoming dehydrated.

The home was clean and had processes in place to maintain a hygienic environment.

Is the service effective?

People's health and care needs were assessed and their care plans and assessments were reviewed monthly. Specialist dietary, mobility and equipment needs had been identified in people's care plans where required. This showed that people were having care delivered effectively or in accordance with their assessed needs.

It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well.

Is the service caring?

People were supported by staff who were understanding and sensitive to their needs. We saw that staff showed patience and gave reassurance and encouragement when supporting people. We saw that people living at the home appeared comfortable with positive body language in the company of the staff. This told us that staff took the time to understand and communicate with people despite their disability.

Visitors told us that they had no concerns about the home 'I feel happy I can go home and have no worries he is being looked after wonderfully' and 'I am always contacted if there are any changes they keep me informed'.

Is the service responsive?

The home had appropriate systems in place for gathering, recording and evaluating information about the quality and safety of the overall service. Systems were in place to make sure the acting manager and provider learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

People knew how to make a complaint if they were unhappy. Complaints that had been received since our last inspection had been acted upon promptly and in line with the homes complaints policy and procedure. The home also had a comments book for people to record concerns when they visited the home. People can therefore be assured that the home acts upon complaints, they are investigated and action is taken as necessary.

Is the service well-led?

The provider Sanctuary Care had put in place an experienced acting manager temporarily from their higher management team while the registered manager was absent from the home. This meant that the provider had ensured the home was managed by a competent person in the absence of the registered manager.

The provider undertook a monthly compliance visit. This showed that they worked with the acting manager, deputy manager and the staff to ensure the standards that people expected at the home were maintained.

The home worked well with other agencies and services to make sure people received their care in a joined up way.

People living at the home with the support of relatives and friends were being asked to complete an annual satisfaction survey for 2014. We were told that the information gathered would be collated and where there were shortfalls or concerns raised these would be addressed. This helped to ensure that people received a good quality service at all times.

People experienced care and support that met their assessed needs. We saw that people who lived at the home took part in a variety of activities. One person told us 'Yes, I'm happy here. They (the staff) do a good job', 'There is always something going on' and 'they are always very helpful'.

The home had reported a significant medicines error to the local safeguarding team. The safeguarding team were satisfied with the actions taken by the home. We found that the home had taken appropriate actions in relation to this incident. The manager explained that the homes medicines management systems required some improvements and we found that they had a plan in place to do this.

There were enough qualified, skilled and experienced staff to meet people's needs at the time of this inspection visit. The home was using a high number of agency staff however they had contracts with the agencies in order to provider regular staff. We saw evidence that the home was advertising for permanent staff.

People were protected from the risk of abuse because reasonable steps had been taken to identify the possibility of abuse and to prevent abuse. Relatives that we spoke with told us they were happy with the care their loved ones received. They said if they had any concerns they would speak to any of the staff.

There were enough qualified, skilled and experienced staff to meet people's needs at the time of this inspection visit. However, a relative told us that they were 'concerned that all the really longstanding, loyal staff had gone'. Another relative told us 'there are not really enough staff. At meal times there are not enough staff'.

The provider did not have an effective systems to regularly assess and monitor the quality of service that people receive.

Not all appropriate records had not been maintained at the home and not all of those that had been maintained were accurate .

People that we spoke with made positive comments about the way they were looked after; "I am very satisfied with the way I am looked after", "I get the help I need, but sometimes have to wait for staff to be available to help me" and "the staff are angels."

However, we saw some incidents of people acting aggressively to others who lived at the home. Staff told us that there were not enough staff to meet the mental health needs of people living at the home or to spend quality time with people. We saw that there were not enough staff to respond to the assessed needs of some people's during our inspection.