Ferndale Court Nursing Home

People’s experience of using this service:

Since the previous inspection the registered provider has worked hard to address the issues identified and improve the quality of the care. A turnaround manager had been employed and along with the regional manager and quality team, had made significant improvements. These improvements were ongoing. The new leadership team were dedicated to making further improvements and we found they had promoted an open culture, continuous improvement and person-centred care.

Overall, people and relatives were complimentary and positive about the care and support they received. Staff described the management team as very supportive and approachable, telling us the service was now much more organised. Effective systems were now being followed to check on the quality and safety of the service and improvements were made when required. These improvements need to be consistent and sustained.

Risk assessments were carried out and action taken to reduce risks to people. However, we found examples where actions to manage risks had not been followed robustly and needed further improvement. We made a recommendation in relation to the use of sensor beams.

Improvements had been made to ensure safeguarding procedures were followed and people were protected from abuse or harm.

There were sufficient staff to meet the needs of people in a timely way. Overall, we found that medicines were managed safely.

Significant improvements had been made to the cleanliness of the building. The building and equipment were now safely maintained.

The management team had addressed concerns relating to the dining experience and people were positive about the food and drink available. Any nutritional risks were monitored and acted upon.

Some improvements had been made to ensure staff acted in accordance with the Mental Capacity Act 2005 (MCA). However further improvements were needed to ensure staff fully understood the MCA and appropriate assessments and best interest decisions were carried out where necessary.

Staff were now trained to carry out their roles effectively and received supervision from the management team. We received very positive feedback from relatives about the sensitive and responsive nature of the end of life care provided by the staff.

The management team had worked hard to coach staff and support them to ensure the care provided respected people’s privacy and dignity. People told us staff were kind and caring.

Improvements had been made to care plans, however we found further improvements were required to ensure they included all specific details and that all charts were fully completed.

Improvements had been made to ensure records relating to complaints were fully completed. People felt able to raise any concerns and knew how to make a complaint if necessary.

Quality assurance systems were in place and were being used more effectively to monitor key aspects of the service. However further improvements were needed to ensure staff always understood and followed guidance and changes were communicated effectively.

Audits and checks were completed on a regular basis by the management team and registered provider to identify areas of improvement. A detailed home improvement plan was being implemented.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore this service is now out of Special Measures.

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

Rating at last inspection: Inadequate (Published 23 November 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service had improved from inadequate to requires improvement overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve and meet the breaches in Regulations 18 Staffing and 17 Governance of the Health and Social Care Act Regulations 2008 (Regulated Activities) 2014.

The provider’s action plan had all actions signed off by the previous registered manager dated 21 December 2017. This meant that the provider confirmed to us in their action plan that they would have completed all their actions to meet the legal requirements of Regulations of 18 Staffing and 17 Governance of the Health and Social Care Act Regulations 2008 (Regulated Activities) 2014 by 21 December 2017.

On this inspection we found the provider had not ensured that sufficient numbers of suitably qualified, competent skilled and experienced persons were being deployed effectively. The registered provider had also failed to ensure that their systems were being implemented or followed effectively to assess, monitor and improve the quality of the service. Furthermore, the registered person had failed to maintain an accurate, complete and contemporaneous record in respect of each service user, including a complete record of complaints.

We found the provider had not met their legal responsibility to meet the breaches from the last inspection namely, Regulation 17 Governance and Regulation 18 Staffing of the Health and Social Care Act Regulations 2008 (Regulated Activities) 2014 by 21 December 2017. This was due to the provider’s governance systems not being effective in ensuring continuous improvements were being made or sustained. Staffing numbers/deployment of staff was having an impact on the care delivery for people living at the home. In addition to these continued breaches of the regulations we also found the provider was in breach of Regulation 9, 10, 11, 12, 13, 14, 15 and 16 on this inspection.

You can see what action we told the provider to take at the back of the full version of the report. 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.

Ferndale Court 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.

The care home provided care and treatment for up to a maximum of 58 people. Ferndale Court Nursing Home has two floors with a passenger lift up to the first floor. People living at the home required nursing or residential care. There were people receiving care who were living with dementia.

A registered manager who was present during our inspection had registered with us on 10 May 2018. 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.

The service was not always ensuring people received a safe level of care. Staffing numbers/deployment of staff was not effective in always meeting people’s care needs. For example, we observed one person had not had personal care in a timely manner.

People’s dignity was not always being upheld with a mixed approach observed by staff. Some staff were heard speaking over people whilst rushing the care being delivered. One warm, positive, interaction was observed between staff and a person living at the home.

People were not always receiving enough to eat and drink which we viewed in the records and from our own observations.

Only one person was receiving End of life care at the time of our inspection. We found they were not receiving person centred care which was taking into account their wishes or preferences.

We had concerns regarding the cleanliness of the first floor within the home and regarding repairs not being actioned in a timely manner. The provider took action and by the third day of the inspection the home smelt fresher and actions were taken to make repairs as quickly as possible.

The staff we spoke with told us they wanted to deliver person centred care but they were unable to due to the increasing high dependency needs of people and because there was not enough staff. We observed task led care being provided on this inspection.

We observed unsafe moving and handling techniques used by staff on this inspection. We found 20 staff’s training in moving and handling had expired.

Staff were not receiving regular supervision or appraisals. We found staff had received an induction.

The service had a Mental Capacity Act 2005 policy in place however, we found there was no Mental Capacity Act 2005 framework in place within the records for people who lacked capacity or who had fluctuating capacity to be supported in making decisions.

Not all appropriate Deprivation of Liberty authorisation applications had been sent to the local authority. We also found there were a high number of statutory notifications not sent to the Care Quality Commission which is a legal requirement.

The provider’s own safeguarding system was not being followed consistently to always ensure people were being protected from alleged abuse. For example, we observed unexplained bruising/marks which had not been recorded or reported to the safeguarding authority. We found 21 staff’s safeguarding training had expired. The provider responded to our concerns immediately. They checked everyone living at the home and completed a body map.

We found there were complaints being made within the home with no record of the actions being taken by the registered manager.

There were not enough activities for people within the home and people were not being provided with enough stimulation. The design of the premises and the building’s interior was not providing a homely environment for people.

There were quality audits being completed within the home by the registered manager and the provider, however, they were not effective in ensuring actions were completed to ensure improvements were being made.

During the inspection we found medicines were being managed and stored appropriately however, we were provided with notifications following the inspection informing us of some medication errors highlighted to them by a visiting nurse. The provider confirmed to us how they were dealing with these errors.

Recruitment files we checked demonstrated robust practices including Disclosure Barring Service (DBS) checks being undertaken.

Advocacy services were in place within the home. Relatives meetings were being undertaken alongside the local authority.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, it will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Since our last inspection in March 2017, we received information of concern regarding the standard of care and treatment provided to people using the service and the overall management of Ferndale Court.

We therefore undertook a focussed inspection on the 25 September 2017 in response to the concerns raised.

This report only covers our findings in relation to the areas of concern. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Ferndale Court Nursing Home' on our website at www.cqc.org.uk.

Ferndale Court Nursing Home is owned by HC-One Ltd (the provider) and is located in the Ditton area of Widnes, close to local shops, pubs and St. Michael's church. The home provides care for up to 58 people.

All the bedrooms are single with en-suite facilities. In addition to lounges and dining areas with drinks making facilities, there is a cinema room and a hairdressing salon. The home is divided into three units. The ‘Blue bell’ nursing unit is on the first floor and at the time of the inspection 27 of the 34 beds were occupied.

The ground floor ‘Primrose’ unit provides personal care for up to 10 people with needs related to a physical disability or frailty, and this was occupied by 10 people on the day of inspection. Also on the ground floor is ‘Sunflower’ unit which provides personal care for up to 13 people with needs related to dementia, and this was occupied by 13 people on the day of inspection. At the time of our inspection visit there were 50 people in total living in the home.

There was no registered manager at Ferndale Court Nursing Home. 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.

A peripatetic home manager had been assigned to oversee the management of Ferndale Court Nursing Home and was present during the day of the inspection, together with the area director.

During this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing and governance.

We found that the registered provider had failed to ensure that effective systems were in place to assess, monitor and improve the quality of the service. We also found that care plans did not always address the holistic needs of people using the service such as behavioural challenges or psychological needs or identify all relevant information such as the type of mattress to be used, the required setting or the positioning needs of people.

Furthermore, care plans and associated records were not always reviewed appropriately and some staff were therefore not clear about people’s support needs. Monitoring charts viewed were also completed to a poor standard and we noted that a few charts had been recorded in advance.

Additionally, the registered person had failed to ensure that sufficient numbers of suitably qualified, competent skilled and experienced persons were being deployed effectively.

You can see what action we told the provider to take at the back of the full version of the report.

We have also made a recommendation that records relating to the application of topical creams are reviewed to ensure they provide more detailed information to staff on where and how to apply products.

Furthermore, we have recommended that all rooms are identifiable with room numbers and / or names so that staff and people using the service are able to orientate around the home and to help locate rooms.

We found that the appropriate checks had been made to ensure that prospective employees were suitable to work with vulnerable adults.

Staff also had access to training in infection control and personal protective equipment such as hand sanitisers, gloves and aprons were also in place.

Ferndale Court Nursing Home is located in the Ditton area of Widnes, close to local shops, pubs and St. Michael's church. The home provides care for up to 58 people. All the bedrooms are single with en-suite facilities. In addition to lounges and dining areas with drinks making facilities, there is a cinema room and a hairdressing salon. The home is divided into three units. The nursing unit is on the first floor and at the time of the inspection the 34 beds were all occupied. The ground floor Primrose unit provides personal care for up to 12 people with needs related to a physical disability or frailty, and this was occupied by 10 people on the day of inspection. Also on the ground floor is Sunflower unit which provides personal care for up to 12 people with needs related to dementia, and this was occupied by 6 people on the day of inspection. At the time of our inspection visit there were 50 people in total living in the home.

The last comprehensive inspection was carried out on 17 November 2015. The service was rated as Requires Improvement overall. There were no breaches of regulation, but at the time not all mandatory training was up to date, one person who was obese had not been referred to the dietitian, one person’s care plan had conflicting information about their hydration needs, some people’s care plans had not been updated to reflect changing needs after they’d been in hospital and there was some old information in care files that could have caused confusion for agency staff about what people’s care needs were. There was also no record of attendance at residents’ and relatives’ meetings.

At this inspection we found that most of these matters had been addressed, with the exception of training being up to date, although improvements had been made.

There was no registered manager in place because they had been moved to another home the previous month, but there was an experienced relief manager in place. 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 spoken with told us that they were well cared for and they were happy in the home. They made positive comments, such as : “I would recommend this place to anybody, it is spotless, seems well managed and any problem is sorted within seconds, nothing is ignored” and “This is a great place, everything is good”.

There was an effective quality assurance system in place, which included seeking the views of the people who used the service.

Staff were observed to be very caring and attentive to the people who lived in the home. We could see that staff ensured people's privacy. We saw that bedroom doors were always kept closed when people were being supported with personal care.

People told us that they enjoyed the food and could choose how to spend their day. The home employed an activity organiser who supported people to take part in activities either individually or in groups, which included going out to places of interest.

People received visitors throughout the day and we saw they were welcomed and included. Visitors told us they could visit at any time.

Staff received training to meet the needs of the people who lived at the home including

safeguarding vulnerable people from abuse. People spoken with were confident that any allegations made would be fully investigated to ensure people who lived at the home were safe.

Some people who used the service did not have the ability to make decisions about some parts of their care and support. There were systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

A new manager has recently been appointed and at the time of our visit she was being supported as part of her induction by an experienced manager from another HC-One home. She was also in the process of applying for registration as the home manager with the Care Quality Commission. This is a legal requirement under the Health and Social Care Act.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five 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?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives; the staff supporting them and from looking at records.

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

Is the service safe?

The home was well maintained and a programme of refurbishment had recently taken place in order to ensure the home was pleasant and safe for people living and working there.

Training records highlighted that staff were up to date with all mandatory training needed to support people living at Ferndale Court.

The manager advised us that appropriate procedures, including review were in place should anyone need to be subject to a Deprivation of Liberty Safeguard (DoLS) application or plan. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.

Is the service effective?

The people using the service who were able to tell us said that they were happy living in the home. Comments included; 'staff are very good', 'staff are lovely' and 'the home is lovely, staff are lovely'.

We also received positive comments about the home and staff members from the visitors we spoke with. Comments included; 'the staff are good' and 'they are looking after [my family member] well, staff are very nice' and "the staff are lovely'.

The relationships we saw were warm, respectful, dignified and with plenty of smiles and laughter.

The staff members we spoke with could show that they had a good understanding of the people they were supporting and they were able to meet their various needs.

Is the service caring?

We observed that staff interacted well with residents. They took time to ensure that they were fully engaged with the individual and checked that they had understood. Before carrying out interventions with the people using the service they explained what they needed or intended to do and asked if that was alright rather than assume consent. They also spoke to people informally and acknowledged with a smile as they passed through the home and went about their daily tasks.

All staff said that they felt supported to do their job and had received regular formal supervision. (These are regular meetings between an employee and their line manager to discuss any issues that may affect the staff member; this would include a discussion of ongoing training needs).

Is the service responsive?

The care plans had been written in a person centred manner. This means that the individualised care plans focused on the person's individual assessed needs and on how they could be met. The care plans focused on providing support to an individual in different aspects of their daily life, for example how the person was to be supported with promoting their independence and any issues regarding their health so that they were kept as healthy as possible.

During the previous inspection that took place on the 27 November 2013 we found some issues around the actual numbers of staff on duty and a compliance action which stated that there was not enough qualified, skilled and experienced staff to meet people's needs was made. Following this visit the provider sent us an action plan explaining how the issues would be addressed.

During this inspection we found that the provider had addressed this and no further concerns in the area above were identified.

Is the service well-led?

The staff members we spoke to said that the home was well managed and they enjoyed working there. They spoke positively about the morale within the home and that staffing levels had improved recently.

We saw that the provider had a range of checks completed by the manager and staff on a regular basis. This showed that the provider ensured that there was an effective system to regularly assess and monitor the quality of service that people received.

All five people who used this service told us they were happy there. One person we spoke to said 'the staff are like my family, I know them all by name..., it is marvellous here'. One person told us all the staff we 'very approachable and friendly'. We observed staff as being kind and warm towards people who used the service. All the people we spoke to felt staff maintained their privacy and dignity. When asked all staff were able to tell us how they would maintain people's dignity when providing personal care.

We saw evidence of staff weighing people on a regular basis and were told they informed the GP and/or dietician of any weight loss. Staff were able to tell us how they increased someone's calorie intake and monitored their daily intake of food and drink. We also saw malnutrition screening tools were used to calculate the service user's risk of malnutrition. We spoke to the dietician who said staff liaised well with her and she felt they were knowledgeable about the people who used this service.

All the service users we spoke to said they had no concerns over the welfare of any of the other people living there. Two told us they felt 'safe' there. We spoke to one GP who was visiting a service user who said she had no concerns over service user's welfare; staff appeared very knowledgeable, followed her advice and always liaised well with her.

We saw evidence of minimal agency staff being used. We were told the provider had recently recruited more staff and had improved the staff to service user ratio. Although all seven staff we spoke to and three out of the five users said they still did not have enough staff. Some service users said staff were 'rushed' when attending to them and took long periods to answer the call bell. Three staff members felt it led to bad practice, for example filling in repositioning charts at the end of the shift and not when the care was being provided.

We asked the people living at Ferndale Court about the staff working there, comments included, 'The staff are fine, just been out for a paper for me', 'The staff are looking after me well' and 'The staff are very good.'

We were able to see a 'Thank You' card that the home had recently received. It contained the following note, 'We'd like to thank you so very much for your support, laughs and most of all the care and friendship you gave to us all during our [relatives] stay with you.'

There was a consistent team of staff within the home and we did not have any concerns regarding either their numbers or suitability. The staff members we spoke to were very positive about the home. One of them said; 'Lovely, feels like home.' Another person said, 'By far the best home I have ever worked in.'

The staff members attended regular staff meetings. Information was passed on, issues were discussed and staff or managers were able to raise concerns.