CQC report explained · a residential care home
What the CQC found at Ferendune Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always safely managed, including missing PRN protocols and unsecured prescribed creams. Inspectors found suitable risk assessments, safeguarding procedures, recruitment checks and infection control measures.
- Effective?
- Good
- This question was not covered by this focused inspection, so no rating was given.
- Caring?
- Good
- This question was not covered by this focused inspection, so no rating was given.
- Responsive?
- Good
- People received personalised care and their communication needs were understood. Activities and support for relationships had improved, although activities were still being embedded and did not always fully reflect people's interests.
- Well-led?
- Requires improvement
- Audits were not reliable because identified actions were not always completed or followed up. Inspectors also found gaps in fire safety records and concerns about communication with relatives, staff and visiting professionals.
What inspectors found, October 2021
Ferendune Court rated Requires Improvement; inspectors found kind, personalised care but gaps in medicines checks, fire safety records and management oversight.
This was an unannounced focused inspection on 24 August 2021. Inspectors spoke with people living in the home, a relative, staff and visiting professionals. They also checked care records, medicines records, staff recruitment files and management records.
The home was rated Requires Improvement overall. Safe and Well-led were also Requires Improvement. Medicines were not always recorded safely, some fire safety checks had not been completed since June 2021, and audits did not always lead to action.
The home was rated Good for Responsive. Inspectors found improvements in personalised care, activities and support for relationships. The home was no longer in breach of the earlier person-centred care regulation, but it was in breach of Regulation 17 on good governance.
The CQC asked the provider for an action plan and said it would monitor progress and return for another inspection.
Kind and respectful care
Inspectors found that staff knew people's needs and treated them with kindness, dignity and respect.
“People experienced person centred care from staff who were compassionate and knew people's needs.” from the report
Personalised support
Care plans reflected people's assessed needs and were updated as an ongoing process. People were supported to make choices about their care, food and where they sat at lunch.
“Care plans were developed as on on-going process to reflect what was important to the person.” from the report
Safeguarding and recruitment
Staff understood how to report suspected abuse. The recruitment records checked by inspectors contained the required checks and references.
“The provider followed safe recruitment practices to ensure people were protected against the employment of unsuitable staff.” from the report
Improved responsiveness
The rating for Responsive improved from Requires Improvement to Good. Support for activities, relationships and people's communication needs had improved since the previous inspection.
“At this inspection, we found improvements had been made the provider was no longer in breach of regulation 9 and the rating has improved to Good.” from the report
Medicine records and storage
seriousSome medicines were not managed safely. One person did not have a written PRN protocol, prescribed creams were kept in an unlocked cupboard, and some audit actions remained incomplete.
“People's medicines were not always safely managed. For example, one person who had medicine 'as required'(PRN) did not have an individual protocol detailing how and when these medicines should be administered.” from the report
Weak management checks
seriousAudits were sometimes marked as compliant even when actions had not been completed. This meant the provider could not always assure the quality and safety of the home.
“Audits had been signed off as compliant although not all actions had been completed.” from the report
Fire safety records
seriousRegular fire safety checks were not being completed. Inspectors were told that checks had not been completed since June 2021.
“Fire safety checks had not been completed since June 2021.” from the report
Staffing concerns
needs fixingPeople and staff gave mixed views about staffing levels. Some staff said shortages were stressful and affected the quality of care, although inspectors saw enough staff working on the inspection day.
“Staff told us, "I do have concerns around staffing levels, we are short on the floor, which is stressful and impacts on the quality of care.” from the report
Activities not always matched to interests
minorThe home had introduced activities and themed areas, but inspectors were not assured that all activities reflected people's stated interests and choices.
“We were not assured that all activities being offered completely reflected people's interests and choices as stated in their support plans.” from the report
- 01What has been done to make sure every person who needs PRN medicine has an individual protocol?
- 02How are medicines, including creams and opening dates, now checked and stored securely?
- 03Have regular fire safety checks restarted, and can you show us the completed records?
- 04How do you make sure audit actions are completed and followed up rather than just signed off?
- 05What has changed to improve communication with relatives, staff and visiting professionals?
This was a focused inspection of Safe, Responsive and Well-led only; the ratings for Effective and Caring were not reviewed on this occasion and the previous ratings were used in calculating the overall rating. This explanation was written from the published report of 14 October 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
Ferendune Court was rated Requires Improvement; inspectors found kind care and good training, but staffing, activities and management oversight were not always good enough.
This was an unannounced, full inspection on 23 and 29 May 2019. One inspector and two experts by experience spoke with people, relatives and staff, and reviewed care plans, medicines records, risk assessments, complaints and audits.
People said they felt safe and described staff as kind. Inspectors found safe medicines practice, suitable training, good support with food and healthcare, and respectful care that promoted privacy, dignity and independence.
The main problems were staffing and the way staff were deployed. This affected personal care, waiting times and activities, especially for people who stayed in their rooms. Quality checks had not identified these problems, and there was no registered manager in post.
The overall rating was Requires Improvement. Safe, responsive and well-led were rated Requires Improvement, while effective and caring were rated Good. The home breached Regulation 9 on person-centred care, and CQC asked the provider for an action plan.
Kind and respectful care
People and relatives described staff as kind and compassionate. Inspectors saw staff offering reassurance and protecting people's dignity and privacy.
“People and their relatives told us staff were kind and compassionate.” from the report
Good staff training
Staff had a thorough induction, regular supervision and appraisals. Training included moving and handling, first aid, infection control and safeguarding.
“Staff had undergone a thorough induction programme which had given them the basic skills to care for people safely.” from the report
Safe medicines practice
Inspectors found that medicines were received, stored, given and disposed of safely. Instructions were in place for medicines given only when needed.
“Medicines were safely received, stored, administered and disposed of when no longer needed.” from the report
Support for independence
The home supported positive risk-taking and helped one person take independent walks while keeping arrangements in place for emergency contact.
“As a result, this person was able to maintain their independence while enjoying longer trips out on their own.” from the report
Staffing and waiting times
seriousStaff were not always available in sufficient numbers. Inspectors heard that people waited for help with personal care and that staffing pressures affected people's safety and routines.
“People and their relatives told us there were not enough staff to meet people's needs effectively.” from the report
Limited activities in bedrooms
needs fixingThere were group activities, but people who stayed in their rooms received little meaningful activity or social interaction. Planned activities were rarely provided.
“However, there was a lack of activities provided to people who stayed in their rooms.” from the report
Care did not always reflect preferences
seriousOne person had changed their routine to avoid waiting for a wash. Inspectors said the care provided did not always meet people's needs or reflect their preferences.
“This demonstrated a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak quality checks
needs fixingThe home's audits had not identified the problems with staff deployment and activities. A survey had also raised concerns, but there was no action plan to address them.
“However, the quality assurance systems had failed to identify the issues found at this inspection in relation to deployment of staff and the lack of activities provided to people who stayed in their rooms.” from the report
No registered manager
needs fixingThere was no registered manager at the time of inspection. Other managers were overseeing day-to-day management while a new manager was being appointed.
“There was no registered manager in post.” from the report
- 01How many staff are planned for each shift now, and how do you check that this is enough for people's actual needs?
- 02How do you prevent people waiting too long for washing, bathing or other personal care?
- 03What individual activities are offered to people who stay in their rooms, and how do you record that these have taken place?
- 04Has a registered manager been appointed since this inspection, and who is responsible for day-to-day management now?
- 05What action was taken in response to the concerns raised in the residents' and relatives' survey?
This was an unannounced full comprehensive inspection covering all five key questions; the previous overall rating was Good, published on 21 July 2017. This explanation was written from the published report of 18 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Ferendune Court
5 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- October 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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