CQC report explained · a nursing home
What the CQC found at Ferndene Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks, medicines, infection control, staffing and emergency arrangements were well managed.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- People received personalised support in practice, could make choices, keep relationships and take part in activities. Some care plans still contained generic statements.
- Well-led?
- Good
- Quality checks were effective and managers acted on issues. People, relatives and staff described the management team as open, approachable and responsive.
What inspectors found, February 2023
Ferndene Care Home was rated Good after a focused follow-up, with inspectors finding safe, responsive and well-led care, but some care plans were not fully personalised.
Inspectors visited on 4 and 6 January 2023 without announcing the inspection. They spoke with people, relatives, staff and managers. They reviewed care plans, medicine records, risk assessments, cleaning records and quality checks.
The home was rated Good overall, and Good for Safe, Responsive and Well-led. Inspectors found people were safe, medicines were managed well, infection control was effective, and staffing levels were adequate. People were treated with respect and supported to make choices, maintain relationships and take part in activities.
This was a focused inspection following a previous Requires Improvement rating. The provider had completed an action plan, and inspectors found enough improvement for the home to no longer be in breach of Regulations 12 and 17. Effective and Caring were not inspected during this visit, so their previous ratings were used in the overall rating.
Safety and medicines
Inspectors found that risks were assessed and managed, medicines were recorded safely and staff followed safe administration practices.
“People's medicines were well managed, and people were protected from the risk of infection as the staff maintained good infection, prevention and control practices.” from the report
Infection control
The home had suitable arrangements for preventing and managing infections, including safe visiting, PPE and outbreak procedures.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Choice and relationships
People were supported to make everyday choices, keep in touch with family and friends, and join activities they wanted to attend.
“People were supported to undertake social activities of their choice.” from the report
Management oversight
The home used daily, weekly and monthly checks to identify problems and track improvements in care, medicines, cleanliness and the environment.
“The quality monitoring processes in place at the service were effective in identifying areas where improvements were required relating to all aspects of people's care.” from the report
Care plans were not always personal
minorSome care plans used generic statements rather than enough information about the individual. Managers knew about this and were working through the plans to improve them.
“However, some aspects of people's care plans were not always personalised.” from the report
Snack quality
minorSeveral staff raised concerns about the quality of snacks provided to people. Managers had listened and taken action, but the report says this area was still being improved.
“During our inspection a number of staff raised concerns about the quality of snacks being provided for people” from the report
- 01How have you made sure each person's care plan is personalised rather than using generic statements?
- 02What changes have been made to the quality and choice of snacks since staff raised concerns?
- 03What were the previous ratings for Effective and Caring, which were not inspected during this visit?
- 04How do you check that people's nutritional needs and weight changes are being monitored?
- 05How will the new registered manager keep families informed about concerns, complaints and improvements?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 1 February 2023 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, May 2022
Rated Requires Improvement; inspectors found risks in care, medicines and infection control, with weaknesses in management oversight.
This was an unannounced focused inspection on 23 and 28 March 2022. Inspectors looked only at Safe and Well-led because of concerns about risk management and leadership. They spoke with people and relatives, watched care, talked with staff and managers, and checked care, medicine, recruitment and quality records.
The home was not always safe. Inspectors found that some risks were not properly assessed or followed up. They found problems with medicine stock checks and storage, unclean areas, food safety equipment and the use of protective equipment during a respiratory outbreak.
The home had safe recruitment processes and enough staff were seen to meet people's needs. People were supported to make decisions under the Mental Capacity Act, and visiting arrangements were in place. However, quality checks did not reliably find or fix problems, and communication and responsibility were unclear.
The overall rating is Requires Improvement. Safe and Well-led were also rated Requires Improvement. This is the home's third consecutive Requires Improvement rating. The report says the provider was not previously in breach of regulations, but this inspection found breaches of Regulation 12 and Regulation 17.
Safe recruitment
The home used recruitment checks, including criminal record checks, to help ensure staff were suitable.
“Records showed there were safe recruitment processes in place that ensured people were supported by suitable staff.” from the report
Staffing during the visit
Inspectors found enough staff to meet people's needs and saw staff respond to call bells and support people at lunchtime.
“We found there were enough staff to meet people's needs.” from the report
Mental capacity safeguards
The home was working within the principles of the Mental Capacity Act, with appropriate legal authorisations in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Access to outside support
The home worked with external professionals to help people access support services when required.
“The service worked with external professionals to ensure people had access to support services when required.” from the report
Risks were not followed up
seriousCare plans and risk assessments were not always updated after important changes or incidents. This left people at risk, including a risk of choking and health deterioration.
“This meant they remained at significant risk of choking due to a failure to ensure follow up actions stated were taken.” from the report
Medicine safety
seriousCreams were left where some people could access them, and medicine stock did not always match the records. This meant it was unclear whether people received the correct amount.
“We found multiple discrepancies with people's stock of medicines.” from the report
Infection control and environment
seriousInspectors found unclean communal areas, bodily fluids, unsuitable kitchenette equipment and problems with food temperature records. Protective equipment was not always used correctly during a respiratory outbreak.
“Several areas of the environment were unclean which posed a risk of infection and compromised the effectiveness of cleaning.” from the report
Weak quality checks
seriousAudits and daily checks did not consistently identify or resolve problems. Responsibilities for environmental safety were unclear.
“The provider had failed to ensure there were effective quality monitoring systems and processes in place to monitor quality and safety of the service and maintain oversight.” from the report
Communication
needs fixingRelatives said communication was poor or that they were not kept up to date. Inspectors also found poor communication and unclear responsibilities among staff.
“Relatives informed us communication was an issue and felt it could be improved.” from the report
- 01What changes have you made to ensure care plans and risk assessments are updated immediately after incidents or changes in people's needs?
- 02How do you now check medicine stocks, account for loose medicines and keep creams safely stored?
- 03What has been cleaned or replaced since the inspection, and how are food temperatures and fridge equipment checked?
- 04Who is now responsible for environmental safety, medicine audits and infection control, and how is this checked by managers?
- 05How will you keep families informed about changes, incidents and the improvement plan?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not assessed or rated in this report. This explanation was written from the published report of 20 May 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.
Every inspection of Ferndene Care Home
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- December 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2020Requires improvementSafe: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2019
Registered with the Care Quality Commission on 5 February 2019.
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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