16 March 2021
During an inspection looking at part of the service
Fern Hill House Care Home is a residential care home providing accommodation, care and support for up to 24 people aged 65; some people using the service were living with dementia. Accommodation is provided over three floors. During our inspection the top floor was not in use. There were 17 people living in the home.
People’s experience of using this service and what we found
Since the last inspection, there had been improvements made but time was needed to embed new systems to ensure they were effective and could be sustained. The provider had addressed the serious concerns raised in the fire safety enforcement notice. However, additional work needed to be completed and signed off by the fire safety officer. Quality monitoring systems had improved with evidence shortfalls had been identified and acted on. However, further improvements were needed in areas such as developing action plans and ensuring care records, equipment servicing and medicines management audits were fully effective.
The management of risks to people's health, safety and wellbeing had improved. However, we found areas that could be improved further to ensure staff were provided with guidance about how to provide care in a safe way. Accident and incident management had improved, and lessons were learnt from any incidents. Staff had been provided with the provider’s mandatory safety training. Training and supervision sessions were used to ensure learning and improvements took place. The manager and staff were clear about when to report incidents and safeguarding concerns to other agencies. Relatives had no concerns about the safety of their family members. We observed good interactions between staff and people.
People's medicines were managed and stored safely, and records were clear. However, improvements were needed in relation to recording the application of creams, medicines for disposal and keeping records of medicines ordered. We were assured the provider was preventing visitors from catching and spreading infections and there had been no COVID-19 outbreaks in the home. The service was clean and odour free. During the inspection, the cleaning schedules were reviewed to ensure staff were following safe guidance.
Staff were recruited safely, and records showed there were consistent numbers of staff available to meet people’s needs. Relatives made positive comments about the care and support provided by staff particularly during the pandemic. New care planning records reflected people’s choices and considered people’s diverse needs. People looked settled and happy and we observed them being treated with care and respect. People's views and opinions were sought through day to day discussions and surveys; resident meetings were due to recommence. Relatives confirmed they had been kept up to date and involved in any changes and decisions.
The manager and provider understood their responsibility to be open and honest when something went wrong. Staff said the manager was approachable. The manager and staff worked in partnership with a range of professionals to ensure people received the care and support they needed. The manager was supported by the management team and had enrolled on training to support him with the role. Staff told us they were supported and enjoyed working at the service. Staff and relatives made positive comments about the manager’s contribution to improvement and ongoing communication.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Inadequate (published 15 December 2020).
During this inspection, we noted improvements had been made but needed to be further embedded into daily practice. Therefore, we have identified continued breaches in relation to the management of risk and effective quality assurance systems. We have made a recommendation regarding safe management of medicines.
This service has been in Special Measures since 16 December 2020. During this inspection, the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This was a planned inspection based on the previous rating.
On 10 and 12 November 2020, we carried out an announced focused inspection of this service. Breaches of legal requirements were found with regards to good governance, fire safety, risk management, training and infection prevention control practices. We made recommendations in relation to safeguarding, lessons learned and involvement.
We also served a warning notice for non-compliance with Regulation 17 Good Governance and we made a referral to the fire service who visited and served a fire safety enforcement notice.
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
We undertook this focused inspection to check they had followed their action plan and whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fern Hill House Care Home on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.