Ferndown Nursing Home

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.

This is the first assessment for this newly registered service. This key question has been rated 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 service was in breach of legal regulation in relation to people’s safe care and treatment, safe environment and the ways people’s medicines were managed.

This service scored 53 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although the provider had established a process of learning from events to improve the service, it was not always effective. Openness and transparency about safety was actively encouraged however not fully embedded in the service. Processes to review incidents were not always consistently effective. Incidents and accidents records were completed by staff and reviewed by the management team. However, incidents were not thoroughly scrutinised in conjunction with people’s care records to check if all actions were completed by staff as required.

When identified, lessons were learned, discussed and communicated to staff via handover, team meetings and regular one to one supervision meetings. However, we found that not all risks were dealt with and seen as an opportunity to put things right, learn and improve. For example, we reviewed accidents and incident reports for 3 people who suffered unwitnessed falls and found staff did not completed required 24 hours post-falls monitoring and clinical observations. Completion of post-falls assessments were included in lessons learnt from a recent incident when staff failed to recognise a person suffered a fracture and had developed an infection after they had an unwitnessed fall. This was still not embedded in practice.

Lessons learnt were communicated to staff at the time, and staff have been reminded of the importance of timely and accurate documentation of post-fall assessments, pain monitoring, and fluid and urine observations. The provider had already identified this and started working on improvements to monitor incidents. We will review these improvements at the next inspection.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked with people and those close to them to establish their plan of care and comprehensive individual transition plans prior to the person moving between services. This aimed to eliminate any risks and ensure the person maintained continuity of care. Pre-assessment paperwork was always completed involving people, relatives and partners prior to people moving into the service, and was shared with staff. Assessments of needs were communicated with staff when people moved into the service or returned from a hospital stay via daily handovers.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives confirmed they felt the service provided by Ferndown Nursing Home was safe.

The provider established effective safeguarding systems, policies and procedures and managed safeguarding concerns promptly, using local safeguarding procedures whenever necessary. There was a consistent approach to safeguarding and matters were always dealt with in an open, transparent and objective way. Where required, investigations were thorough.
All staff had received safeguarding training and demonstrated a comprehensive awareness and understanding of their roles and responsibilities. Staff knew how to recognise the signs and symptoms of abuse and who they would report concerns to both internally and externally. They told us they felt confident management would listen and act if they raised concerns.

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. People had the necessary assessments in place to ensure their rights had been fully respected. The provider followed principles and requirements of Mental Capacity Act (MCA) where people were deprived of their liberty, whether under the Deprivation of Liberty Safeguards (DoLS) or through an order by the Court of Protection. There was a clear understanding of DoLS, they were used appropriately and only when it is in the best interest of the person.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Risk assessments were created and maintained within the provider’s electronic record system. However, there were inconsistencies in how the risks were managed, reviewed and updated as things changed. Where potential risks were identified the provider didn’t robustly assess and managedthese risks, such as where people had specific health conditions which could impact on their wellbeing. For example, we reviewed care plan for a person who required support with suction due to occasional refluxand had a specialist medical device in their room. Their care plan did not offer guidance for staff on how to safely use and maintain the device. This meant people were at risk of not having their needs met due to the condition and performance of medical device that was not maintained as per manufacturer instructions.

People’s involvement in risk assessment and decision‑making was inconsistent, and their care plans did not always reflect individual preferences or provide clear, personalised strategies and guidance for staff. For example, we reviewed care plans for 2 people who needed support at times of distress and anxiety. Their care plans did not offer detailed guidance for staff on how to support them using person-centred interventions, gentle distraction to de-escalate or to check underlying physical triggers such as pain or discomfort first. Staff did not always have the guidance necessary to keep people safe while at the same time supporting enablement and independence. This meant people were at risk of not having all their needs met. The provider had already begun taking steps to strengthen people’s involvement in risk management and ensure care planning becomes more consistent.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider’s approach to assessing and managing environmental risks was inconsistent. Although the provider worked with professionally qualified people to complete necessary environmental and equipment checks, these arrangements were not effective and did not identify shortfalls found at this inspection. For example, the safety of the premises, communal and personal spaces (such as bedrooms), and the living environment were not always effectively checked and managed to support people to stay safe. The sluice rooms on both floors were used to store potentially harmful chemicals. There were not kept securely locked and doors had no locks fitted. This meant people were at risk of harm should they came into contact with them. The provider took immediate actions and locks were fitted to ensure sluice rooms were kept securely locked.

Most windows did not have required window restrictors installed. Providers have responsibility to take risk mitigation measures to prevent falls from windows. Further, all radiators in the premises were uncovered and most radiators and associated pipework operate at temperatures that present a burn risk. Providers have responsibility to reduce the risk of burns from hot surfaces by providing heat emitters with low surface temperatures or guarding the heated areas by providing radiator covers or covering exposed pipework.

In addition, we found wardrobes in people’s bedrooms had no wall anchors. Although there are no specific guidelines about this, providers have a responsibility to risk assess hazards and heavy furniture items such as wardrobes could tip should someone fall against them or use them for support.

We raised the concerns with the provider, and they took immediate actions to address shortfalls. We conducted a second visit to the service on 17 June 2026 and found window restrictors were installed on all windows, most radiators had covers and wardrobes were anchored to the walls in people’s bedrooms. The manager told us they were implementing improvements to their health and safety monitoring systems. We will assess new arrangements to monitor the safety and upkeep of the premises at the next inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough competent staff on duty when we visited. Staff had the right mix of skills to make sure that practice was safe, and they were able to respond to unforeseen events. The provider regularly reviewed staffing levels and adapted them to people’s changing needs. Staff told us that they felt supported and received appropriate training and supervisions to enable them to fulfil their roles. People were supported by a regular staff team, and care was delivered through agreed routines which meant people experienced continuity of care.

People and their relatives felt there were sufficient staff on duty. We received mainly positive feedback about staff. People and their relatives expressed that they were generally happy with staff supporting them. Relatives described staff as, “excellent”, “lovely, considerate and caring”, “nice and approachable”.

Appropriate recruitment checks were carried out as standard practice. Recruitment processes were robust, and staff were recruited safely.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected from the risk of infection because the premises and equipment were kept clean and hygienic. They were supported to maintain their own personal hygiene in line with their needs and preferences.

Staff had completed infection prevention and control (IPC) training with regular updates and understood their roles and responsibilities for maintaining high standards of cleanliness and hygiene in the premises and their own personal hygiene, including hand hygiene. Housekeeping staff told us they conducted daily cleaning schedules and checks to ensure processes were being followed and all areas were being cleaned. During the site visit we saw cleaning taking place. Cleaning records demonstrated effective cleaning routines.

We observed the service was clean and free from odours. Personal Protective Equipment (PPE) such as disposable gloves and aprons was available throughout the service, and we observed staff using PPE safely and appropriately.

Managers at the service had oversight of IPC and carried out regular audits and checks of all aspects of infection control. The provider’s IPC policy was up to date. Infection prevention and control procedures were robust, in line with the providers policy.

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

The provider had medicine management policy in place however it had not always been followed. For example, not all medicines were labelled with opening dates. We found 6 people had creams and 1 person had insulin pen which were opened but not labelled. This placed people at risk of receiving medicines that had been opened longer than the recommended time which could be less effective.

Personalised protocols were not in place for all medicines prescribed ‘when required.’ For example, we reviewed records for 6 people who had medicines prescribed to support them with increased agitation and anxiety. Their care plans did not offer guidance for staff on how to support them with agitation and anxiety including suggested strategies to try prior to administering ‘when required’ medicines. The manager arranged to immediately update the documents.

People’s preferences about how they liked to take their medicines were not always considered and recorded in their care plans. People’s care records were not effectively reviewed to reflect changes in people’s needs and preferences.

Staff told us they had training, and competency checks to make sure they gave medicines safely and felt well supported regarding medicines management. They were able to describe how medicines errors or incidents were recorded and followed up, and they knew the procedure to follow if people refused to take their prescribed medication. Medicines’ incidents or errors were reported and investigated.