CQC report explained · a nursing home
What the CQC found at Fernbrook House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2022
Fernbrook House was inspected but not rated; inspectors were assured about infection control and safe visiting.
This was an unannounced, targeted inspection on 24 February 2022. Inspectors looked mainly at infection prevention, COVID-19 visiting arrangements and staffing pressures.
Inspectors were assured that the home used PPE safely, carried out testing, followed infection control guidance and had an up-to-date policy. They also found that people could receive visitors safely, with screening and visits in people's rooms.
The home was inspected but not rated. This report does not give an overall quality rating or a rating for the wider quality of care.
Infection control training
Staff had training in infection prevention and control and how to use protective equipment.
“All staff had received training on infection prevention control and how to use PPE effectively.” from the report
Testing and outbreak response
People and staff were tested regularly. The registered manager acted quickly when positive results were found.
“People and staff had regularly been tested for COVID-19 and where positive results had been returned the registered manager had acted quickly to support people and mitigate risks.” from the report
Safe visiting
People were supported to receive visitors, with screening arrangements in place and visits taking place in people's rooms.
“People were supported to have visitors. The registered manager was following government guidance on screening visitors to mitigate the risk of COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you managing any current staffing pressures, and could they affect people's care?
- 02Are visitors still screened and supported to visit safely, and where do visits take place now?
- 03How often are people and staff tested when there is a suspected or confirmed infection?
- 04How do you check that all staff use PPE correctly?
- 05What arrangements are in place if an infection outbreak occurs?
This was a targeted inspection of infection prevention and control, visiting arrangements and staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 15 March 2022 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, February 2021
Fernbrook House was rated Requires Improvement; inspectors found kind care and enough staff, but medicines records and quality checks were not reliable enough.
This was a targeted inspection in December 2020. Inspectors checked whether earlier concerns about medicines and other legal requirements had been addressed. They spoke with people living in the home, staff, managers and nine relatives, and reviewed a limited number of records.
People were generally supported safely by staff who knew them well. There were enough staff, relatives gave positive feedback, and inspectors saw kind and attentive care. Infection control measures had improved, including steps to reduce the spread of COVID-19 and help people keep in touch with families.
The main problem was that medicines records and care guidance were not always complete or accurate. This could have put people at risk if temporary staff had needed to provide care. The home corrected the immediate problems after the inspection, but its checks had not found them and the improvements still needed to be sustained.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home was still in breach of Regulation 17 about good governance. The earlier warning notice about medicines did not require further action after this inspection.
Enough staff
Inspectors found enough staff to meet people's needs. Staff monitored a person who needed continual supervision because of falls risk.
“During our visit we found there were enough staff.” from the report
Kind and attentive care
Inspectors observed caring support, and relatives described staff as patient, professional and committed to the people living in the home.
“We observed staff to be caring and attentive.” from the report
Improved infection control
The provider had addressed earlier infection control concerns and was using measures to reduce COVID-19 risks while maintaining family contact.
“The provider's infection prevention and control policy was up to date and being implemented pro-actively to minimise the spread of COVID-19.” from the report
Prompt response after inspection
The provider corrected the medicines records and guidance problems promptly after inspectors raised them, and carried out detailed checks for everyone.
“The provider and the management team responded promptly and effectively.” from the report
Positive outcomes
Inspectors found examples of people achieving good outcomes, including a person at risk of malnutrition who had gained weight.
“Feedback from relatives was good, and we found people achieved good outcomes” from the report
Incomplete medicines guidance
seriousSome care plans did not contain enough information for temporary or emergency staff. Some were missing photographs, and guidance about when extra medicines were needed was not sufficient.
“There was not appropriate guidance should temporary or emergency staff need to support someone safely.” from the report
Weak quality checks
seriousPlanned medicines audits were missed, and checks that did take place did not identify the problems found by inspectors. The provider could not easily show what action had been taken.
“The provider had failed to carry out the planned medicine audits for November 2020.” from the report
Tired property and clutter
minorRefurbishment was ongoing. One communal area had boxes that made cleaning more difficult, although the property was clean on the inspection day.
“One of the communal areas was cluttered with boxes, which made cleaning more challenging.” from the report
- 01How do you now make sure medicines records and care plans are complete and accurate for every resident?
- 02What information would a temporary or emergency member of staff receive before giving medicines or providing care?
- 03How often are medicines audits completed, and how do you record and follow up any actions?
- 04What evidence can you show that the improvements made after this inspection have been sustained?
- 05What is the current timetable for completing the refurbishment and improving storage in communal areas?
This was a targeted inspection of specific concerns under Safe and Well-led, with infection prevention and control also reviewed; it did not assess every part of these key questions or the other three key questions. This explanation was written from the published report of 4 February 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.
Every inspection of Fernbrook House
5 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 January 2011.
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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