Ferfoot Care Home

Ferfoot Care Home provides accommodation and personal care for up to 52 people. Accommodation is provided on two floors accessed by stairs and a lift. There are communal rooms for people to use and a secure garden accessed from the ground floor. At the time of the inspection there were 26 people living at the service, some of whom had dementia.

People’s experience of using this service and what we found

Risks to people’s safety were identified and action taken to mitigate risks. This included involving healthcare professionals if needed and obtaining specialist equipment. Risk management plans were reviewed on a regular basis with a monitoring system called ‘resident of the day’. Where additional monitoring was taking place, staff completed records accurately and at the time of the activity. Senior team members regularly checked the monitoring records to make sure information was accurate.

People had their medicines as prescribed by staff who had training on how to administer medicines. Staff also had their competence checked to make sure they were safely managing medicines. People were able to see their GP or other professionals as and when needed. Staff liaised with a range of professionals to make sure people’s health needs were met.

People were being supported by staff who knew them well. Comments from people and relatives about the staff were positive. Staff were described as kind and caring, and we observed care being provided in a dignified way. People had their own care plans which contained a range of information about people’s needs. This included some life history information so staff could get to know and understand people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff had training on a range of subjects and had support from the registered manager and provider. There were regular team meetings and opportunity for staff to have supervision. Staff told us communication at the home had improved and they felt well supported by the management. Staff had been recruited safely and there were enough staff on duty to meet people’s needs. The provider told us recruitment had been challenging in recent months, so they were supporting the home by not taking many new admissions. They wanted to make sure they had enough staff to meet people’s needs safely.

The home was being kept clean by a team of domestic staff who had cleaning schedules in place. Some areas of the home had been re-painted and there had been some refurbishments. New furniture had been bought and the provider planned more improvements in the near future.

People were able to have visitors in their rooms. All visiting had to be pre-planned so the home could monitor numbers of people in the building. Visitors had to take a Lateral Flow Test prior to being able to enter the building. They were also expected to wear personal protective equipment (PPE). Any professionals or expected contractors were required to demonstrate they had been vaccinated against COVID-19 before being able to enter the home.

Staff had plenty of PPE to use and had been trained on using it safely. Staff had been trained on working safely during COVID-19 and had updates on good practice for infection prevention and control. The provider had regular calls with managers to keep them updated with government guidance. Changes and updates were cascaded down to staff with daily heads of department meetings.

Quality monitoring systems were in place. The registered manager told us they carried out their own unannounced spot checks during the night or very early in the morning. The provider also supported quality monitoring by carrying out regular audits and with regional management visits. There was a complaints procedure in place and people and relatives had opportunities to share their views.

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 requires improvement (published 24 June 2021) and there were three breaches of regulations. We served the provider Warning Notices for the breaches of regulations 11 and 17 and a requirement notice for a breach of regulation 18. We returned to carry out a targeted inspection on 10 August 2021 to check action had been taken in relation to the Warning Notices. We found the provider had taken enough action to no longer be in breach of regulations 11 and 17.

Why we inspected

We undertook this inspection to check the provider had followed their action plan and to confirm they now met legal requirements. In addition, at the comprehensive inspection in April 2021 we judged well-led was inadequate. When a key question is rated inadequate, we return within six months to review the key question.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ferfoot Care Home on our website at www.cqc.org.uk.

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.

Ferfoot Care Home provides accommodation and personal care for up to 52 people, some of whom live with dementia. People have their own rooms and access to communal areas such as lounges, dining areas and a secure garden. Accommodation is provided over two floors accessed by stairs and lifts. At the time of the inspection there were 34 people living at the service.

People’s experience of using this service and what we found

At the last inspection we rated the service requires improvement overall. We found breaches of Regulations and issued two Warning Notices in response to concerns about good governance and need for consent. This targeted inspection was to check the required improvement had been carried out and the service was compliant with Regulations.

Since the last inspection there was a new registered manager. Staff told us they were approachable and visible at the service. Staff told us the registered manager was supporting them to carry out the required improvement.

Quality monitoring had taken place and identified improvements. The provider had completed a service improvement plan following the last inspection and reviewed it weekly. Senior management discussed improvements needed and cascaded the information to staff at the service. Action plans had been shared with CQC and the local authority on a weekly basis.

People had their medicines as prescribed. Times of medicines had been reviewed to make sure people were not unnecessarily woken up to have their medicines. All handwritten recording entries on people medicines records were signed by two members of staff. This was to reduce the risk of transcribing errors.

Risks to people’s safety had been reviewed and management plans put into place. These had been reviewed since our last inspection. We found safety measures such as sensor mats were plugged in and working. Where people had not been able to consent to their use staff had carried out the required assessments and best interest processes.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s medical conditions had been reviewed so up to date and current guidance was in place to support staff to know what to do. Daily monitoring records were accurate and completed in a timely way.

People were able to have visitors. Any visitors had to carry out a Lateral Flow Test (LFT) which gave a quick result as to whether visitors had COVID-19. All visitors were provided with personal protective equipment (PPE) to wear while at the service.

People and staff were tested regularly for COVID-19 as per the government guidance. Any positive test was reported to local and national public health agencies and guidance followed. People and staff had been vaccinated for COVID-19.

Staff had received training and guidance on working safely during the pandemic. They were provided with appropriate levels of PPE and had areas where they could put it on and remove it safely. There was guidance available around the home to inform on how to wash hands safely and about COVID-19.

The home was clean and domestic staff had schedules to follow. A maintenance programme was in place to upgrade some areas and carry out planned work to the environment. Staff tried to open windows and space seating out where possible to enable social distancing. The provider had identified additional staff rest rooms to enable staff to have breaks and social distance.

Staff had been provided with supervision and had meetings to discuss what was happening in the home. This also gave the provider the opportunity to discuss and reflect on lessons learned for the service. The provider also shared serious incidents that had occurred in other homes they managed so learning could be cascaded throughout the company.

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 requires improvement (published 22 June 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvement had been made and the provider was no longer in breach of Regulations 11 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we issued in relation to breaches found for Regulations 11 and 17 had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

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.

Ferfoot Care Home provides personal care for up to 52 people, some of whom live with dementia. At the time of inspection there were 44 people living at the home. Accommodation is provided over two floors accessed by stairs and a lift. There are communal rooms such as lounges and dining areas. The home has a small secure garden for people to access from the ground floor.

People’s experience of using this service and what we found

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

There were concerns about the culture at this service as it was not person-centred. The registered manager was not aware of how some staff were working. This placed people at risk of harm as the practice was undignified and unsafe at times. We observed that people were being woken at 6am to have medicines without any medical reason. We observed one person did not have their belongings in their room, staff had removed them and placed them on a different floor. We were not able to see why this action had been taken.

People’s risks had been identified but management plans did not give detailed guidance on how to support people safely. Measures in place to mitigate risks were not always working, for example sensor mats were not plugged in and monitoring records were not being completed consistently and accurately. Behaviour support plans lacked details for staff to know what action was needed when people were distressed.

People’s medicines administration records had not been checked for accuracy when handwritten by two members of staff. The provider could not be assured medicines needing cold storage were being stored safely as temperatures recorded were outside a safe range. People could see healthcare professionals when needed and referrals were timely.

Staff had not received the training they needed to support people effectively, safely and in a person-centred way. Staff told us there was not enough of them to support people safely. Whilst we saw there were enough staff deployed during our visits, we have made a recommendation about staffing numbers. People were being supported by staff that had been recruited safely.

Quality monitoring systems were in place but not routinely effective in identifying shortfalls. Care plan audits were not identifying conflicting information and medicines audits had not identified the shortfalls we observed. Accidents and incidents had been reviewed but there was limited evidence of learning across the providers services. There was a registered manager in place who was approachable. We heard mixed feedback about their management approach which we have shared with the provider.

The home was clean and domestic staff had schedules to ensure thorough cleaning was carried out. Staff were seen to be wearing appropriate PPE and following good infection prevention and control practice. Staff told us they had received training for using PPE safely and had good supplies throughout the COVID-19 pandemic.

There had been no cases of COVID-19 at the home and people and staff were being tested regularly following government guidance. Visiting was being supported indoors and outdoors. Systems were in place to screen visitors, complete an LFT test and supply them with PPE to use whilst at the home. We observed relatives indoors visiting people during our site visit.

The provider had kept people, relatives and staff updated throughout the pandemic and reviewed policies when needed to follow national guidance. People had been supported to stay in touch with relatives using different communication methods. Activity staff were employed and supported people to engage in activities they enjoyed.

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 requires improvement (published 10 December 2019) and there was one breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations. This service has been rated requires improvement or inadequate for the last six consecutive inspections.

Why we inspected

We undertook this focused inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about the managers approach, people being woken up very early in the morning, unsafe medicines management, people not receiving care in a timely way and poor moving and handling practice. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with supporting people who lack capacity to make their own decisions, so we widened the scope of the inspection to become a comprehensive inspection which included all of the key questions.

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

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 we will 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.

We have identified breaches in relation to staff training, supporting people with consent and provider and management oversight and governance.

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.

Follow up

Following the inspection we met with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider and we will work alongside them and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Ferfoot is a residential home for up to 52 people, most of whom live with dementia. At the time of our inspection there were 47 people using the service. The home was divided into the ‘old’ and ‘new’ building. Both areas had bedrooms, bathrooms and communal areas such as lounges and dining rooms. Rooms on the first floor were accessed by a lift. There was a small enclosed garden and some parking.

People’s experience of using this service and what we found

Since our last inspection the provider had made improvements to the environment for people living at Ferfoot Care Home and improved their recruitment of staff to make these processes safer. However, at this inspection we identified concerns around record keeping which meant the provider could not be sure they were delivering care to meet people’s needs in all areas.

People’s records were not always up to date, completed in full or contemporaneously. Risk management plans contained some conflicting information or required further detail. The provider used a system to audit care plans monthly, but this system had not identified missing information or conflicting information. People’s monitoring records were not completed in full or accurately to enable staff to monitor some health needs. We were assured by the registered manager this was a recording issue not a concern about practice and we observed limited impact to people during our inspection.

Staff carried out monthly quality monitoring for some areas. Whilst this had identified some issues such as medicines records, it had not identified the shortfalls we found during this inspection. The provider had a condition on their registration which required them to submit a monthly report to CQC following an audit of care plans and risk assessments. We found the provider had not identified all of the records issues through their own internal audit systems.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice. People’s capacity had been assessed and where people lacked capacity a best interest decision had been made. The provider was reviewing the documentation it used for this process.

Staff were recruited safely. Staff were trained and supported in their role and were provided with supervision and were able to attend staff meetings. There were sufficient numbers of staff available which the provider reviewed using a dependency tool. Staff were knowledgeable about safeguarding and there were systems in place to keep people safe.

People's risks in areas such as malnutrition and moving and handling had been assessed with guidance in place for staff to follow. The environment had been assessed for safety with regular checks carried out to systems such as fire alarms and moving and handling equipment. The home was clean and fresh, and staff were seen to follow good infection prevention and control guidelines.

People were being cared for by kind staff who knew them. We observed many kind and caring interactions between people and staff with staff responding to people’s need for comfort. People were involved in their care as much as possible. Where appropriate relatives were involved in processes such as care reviews and meetings. People could have visitors at any time.

There was a registered manager in post who was visible. Complaints had been dealt with and recorded. The registered manager was supported in their role by a regional manager who visited regularly and was available on both days of our inspection. The home had good links with the local community and worked regularly with various healthcare professionals.

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

Rating at last inspection - The last rating for this service was Requires Improvement (report published 10 December 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We had imposed a condition on the providers registration for this service to receive a monthly report of their quality monitoring audits and analysis of incidents. This condition will remain in place. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Ferfoot Care 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.

Ferfoot Care Home accommodates 52 people in one building. On the first day of the inspection, there were 39 people living at the home. The home was registered to support people living with dementia and their nursing needs, over the age of 65 years.

The building was divided into two adjoining units. Each unit contained people’s bedrooms, a lounge and quiet lounge, a dining room and communal bathrooms and toilets. There was a central kitchen and laundry room.

At the inspection in September 2016, we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result, we placed a condition on the provider's registration. This required the provider to notify the Care Quality Commission, on a monthly basis, of the action being taken to address the shortfalls identified. The provider has adhered to the condition. At the following inspection in May 2017, improvements had been made and the home’s rating was changed from inadequate to requires improvement. At this inspection, further improvements had been made.

The registered manager left employment at the home in May 2018. A manager from within the organisation was covering the role. They said they were in the process of registering with the Care Quality Commission to become the registered manager. 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.

There was positive feedback about the new manager and the improvements that were being made. There was an on-going improvement plan and the manager had “put a hold” on new admissions until changes had been embedded. The admission criterion had been reviewed to ensure the home stabilised and there were clear assurances people’s needs could be met.

The cleanliness of the environment had improved and there was less odour. Carpets had been replaced with flooring that could more easily be cleaned. There were however, some areas such as communal toilets that required additional focus.

Some risks to people’s safety had not been identified. This included an urn in the dining room and a propped open fire door, which led to steps to a lower level. Action was taken to address the risks once brought to staff’s attention.

New staff were being recruited using safe recruitment practice and focus had been given to staff training. The training, particularly that of dementia care had improved interactions and an understanding of the person’s condition. However, some practices such as a music entertainment activity and the lunch time meal experience, were not conducive to some people’s needs.

People could personalise their bedrooms yet other areas such as the corridors were bland. There were limited pictures, signage and textures which did not enable people to find their way around easily. A senior manager told us consideration was being given to brightening the environment. This included painting people’s bedroom doors white.

Incidents, which involved falls and behaviours that challenged had been analysed. This had identified the majority of incidents had occurred during the late afternoon and evening. To minimise further occurrences, the numbers of staff were increased to ten. This had worked well and a decrease in incidents had been seen.

Improvements had been made to the planning of people’s care. Care plans were much more detailed and person centred although some information, particularly around people’s health care needs was more limited. Risks such as falling, choking, malnutrition and the development of pressure ulceration had been assessed and were being appropriately addressed.

People had enough to eat and drink. This included a choice of each meal and regular sweet and savoury snacks throughout the day. Any weight loss was monitored with additional and fortified foods given as required.

People were encouraged to make decisions and staff asked for consent before undertaking any care intervention. Staff promoted people’s dignity although some people had debris under their fingers nails. Staff explained the reason for this but such detail was not documented in the person’s care plan.

Improvements had been made to the safe management of medicines. Staff followed procedure and took their time when administering people’s medicines. Information was available for staff regarding “as required” medicines although not all was personalised to show the person’s needs or preferences.

People were encouraged to remain healthy and had good access to health care.

Ferfoot Care Home provides accommodation and nursing care for up to 52 people. At the time of our inspection, 41 people were resident at the home. The majority of people were living with dementia and had complex care needs.

At this inspection, sufficient action had been taken to remove the service from special measures. However, further work was required to ensure a “good” service. In addition, all improvements required time to be properly embedded and sustained.

There was a registered manager in post. 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 registered manager was available throughout our inspection.

Improvements had been made to people’s safety. However, one altercation occurred and we needed to intervene to minimise the risk of harm. Other than this incident, staff were more proactive, identified potential triggers and used distraction techniques to minimise the risk of an altercation. Staff had received additional training to enable them to support people more effectively with areas such as anxiety, frustration and challenging behaviour. Accidents and incidents were more robustly analysed to minimise further occurrences.

Focus had been given to the numbers of staff required to support people safely. Agency staff were used to ensure these numbers were maintained and recruitment was taking place. However, the home was not operating at full occupancy. This meant additional staff would be required to support further people to the service.

Improvements had been made to the cleanliness of the home. This included less visible areas such as the edging of tables. The unpleasant odour, which was identified at the last inspection, had been reduced although remained in some areas. Old carpets, which held odour, had been replaced with laminate flooring. Further replacement of carpets was planned following redecoration.

Care planning had been developed but there was further work to do, to ensure all information clearly reflected people’s needs. All information was up to date and had been regularly reviewed. There was an evaluation section within the care plan but this was generally a repeat of information rather than a review of the care being given.

Improvements had been made to the accessibility of drinks. However, staff had not identified one person was unwell and needed greater assistance. Staff were monitoring people’s intake more accurately in response to the risks of dehydration and malnutrition. People told us they enjoyed the meals provided and had enough to eat. Menus showed a good choice of food and alternatives were offered according to people’s preferences.

Interactions with people had improved Staff were less rushed and had time with people. They were caring in their manner and on the whole, were attentive to people’s needs. Focus had been given to people’s lives before the onset of their dementia. Information gained had assisted staff to see people differently and develop strategies to ensure effective support. Opportunities for more meaningful social activity provision were being developed. This included activity areas in response to people’s history and interests.

People’s medicines were safely managed. Staff administered medicines in a person centred manner, giving time and any reassurance required.

The registered manager had increased their presence within the home. They regularly toured the environment assessing areas such as cleanliness and observing staff practice. Staff commented positively about the improvements which had been made. They said management systems were more robust, which helped staff perform more effectively. Such systems included improved absence monitoring and better performance management of staff. Staff felt more supported and were looking to develop further. Focus had been given to staff training, particularly in the area of dementia care. This had helped staff develop a better understanding of the way in which people perceived their world.

There were a range of audits, to monitor the service. These were undertaken at varying frequencies. Action plans were in place to address any shortfalls identified. There was an overall improvement plan, which was developed following the last inspection. The registered manager and senior management recognised a lot of work had been completed but there was more to do. They described the situation as “work in progress”.

This inspection took place on 19 September 2016 and was unannounced. We returned on 20 and 22 September 2016 to complete the inspection.

There was a registered manager in post. 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 registered manager is responsible for the day to day management of the home and was available throughout the inspection.

At the last comprehensive inspection on 15 and 18 May 2015, we identified the service was not meeting two of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because potential risks to people's safety were not being properly identified and addressed. In addition, people’s care was not being planned in a way that ensured their needs were met. At previous inspections in April and August 2014, there were also shortfalls in care delivery. Following each inspection, the provider sent us an action plan, which detailed how improvements would be made. At this inspection, there remained breaches in regulation within these areas.

Not enough staff were available to meet people’s needs safely and effectively. Staff were not always aware of people’s whereabouts and some interactions between people were not witnessed. This increased the risk of interactions escalating and people experiencing harm. A high number of people presented with behaviours that challenged and there were many incidents between people. Some people were consistently walking around the home in an agitated state. Not all were properly supported by staff. Management plans were in place but these lacked detail and did not inform staff of the support people required. Not all staff were confident in effectively managing people’s challenging behaviour.

The complexity of people’s needs was not reflected in the assessment or care planning processes. People were not sufficiently supported to minimise their risk of pressure ulceration and specific areas of care were not effectively undertaken and clearly documented. Those people who required assistance were not supported to drink sufficient amounts at regular intervals. People’s fluid intake was not adequately monitored, which increased the risk of dehydration. People were happy with the food they received but accurate records were not maintained when minimal amounts were eaten.

There were positive comments about the staff but interactions with people varied. Some were positive, showed a caring approach and demonstrated staff knew people well. Other interactions however, showed staff’s stresses and frustrations. Some practices did not promote people’s privacy and dignity. This included a person’s catheter bag being visible and a person urinating in the garden. During the inspection, a group of people went out in the organisation’s minibus and some people enjoyed external entertainers. Other people received little interaction and stimulation.

Not all areas of the home were clean and good infection control practice was not always followed. There was a strong unpleasant odour in the entrance area, lounge and some corridors. There were a range of audits to monitor the safety and quality of the service but these were not always effective in identifying and addressing shortfalls. The number of incidents, accidents and infections were regularly calculated. However, further investigations were not undertaken to minimise the number of these occurring. People and their relatives knew how to make a complaint and were encouraged to give their views about the service.

Staff received informal support and more formal supervision to discuss their performance. Staff felt well supported and told us the training they received was good. Records showed staff were up to date with the training, which was deemed mandatory by the provider. Emphasis was given to “Living in My World” training which explored the experiences of people living with dementia. Whilst training was regularly undertaken, a social/health care professional felt additional training in people’s care needs would enhance the care people received.

During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for which we are taking action and will report on this when it is concluded. Two of these breaches were repeated from the last inspection as sufficient action had not been taken to address the shortfalls. 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, 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.

We conducted this inspection because we identified concerns around people's care and welfare and medicine management in April 2014. We found that while the provider had taken appropriate action with regards to people's medicines, there was still room for improvement regarding people's care needs and records.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

The service had systems in place to ensure people's medicines were administered safely or recorded appropriately. The service maintained records of the stock of people's prescribed medicines.

Is the service effective?

The service was not always effective because people's needs were not always being met. Care workers did not record incidents where people were agitated. Staff did not look to see what caused this agitation to improve the person's care.

People's care plans did not always contain current guidance for care workers to meet people's needs. This meant that people could be at risk of inappropriate care or treatment as an accurate record of their care needs had not been maintained.

People were protected from the risks associated with malnutrition, falls and moving and handling. Care workers demonstrated a good knowledge of people's care needs.

Is the service caring?

The service was caring. We found that people benefitted from kind and caring care workers. We conducted short observational framework for inspection (SOFI) observations throughout our visit. We observed that people were treated with respect.

Staff demonstrated good awareness of people's dignity and how they should respect this.

We observed the care being provided to people in the communal areas of the home and examined people's care documentation and supporting records. We spoke with five people that used the service who were able to tell us of their experiences. We spoke with eight members of staff to gain their understanding of how they met the needs of people living in the home.

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

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

Is it safe?

Safeguarding procedures were in place and staff understood their role in safeguarding the people they supported. One person we spoke with told us they felt safe living in the home. People who used the service were cared for by staff who knew how to protect them from the risk of abuse.

We spoke with five members of staff who explained and understood the organisation's whistle blowing policy.They told us it meant to report to someone in authority if they suspected malpractice and/or abuse at work that could compromise people's safety. We saw a copy of the whistle blowing procedure which was prominently displayed so that people were able to read it .This was up to date with the contact information of who staff could report concerns to.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). The registered manager confirmed no one currently living in the home was subject to such an application. However relevant staff had been trained to understand when an application may be required. The registered manager told us about times when they had sought advice in the past from the DoLS team. People's human rights were therefore properly recognised, respected and promoted.

Medicine management systems were not robust. Errors were found in relation to medications that resulted in some people not regularly receiving their medication. We also found that errors were not all reported to the safeguarding team in a timely manner. Following our inspection, where a discrepancy had been identified the provider informed us that they will make the necessary referral. We have asked the provider to tell us what they are going to do to meet the requirements in relation to medicines.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduces the risks to people and helps the service to continually improve people's safety.

Is it caring?

People were supported by sensitive and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. Not everyone was able to verbally tell us of their experience of living in Ferfoot. Therefore we spent a period of two hours observing interactions between staff and people that used the service. The observations we made demonstrated staff supported people in a calm unhurried manner, using communication methods conducive with their individual assessed needs. People were consulted before staff undertook their care routines. For example one member of staff was heard to ask a person if they were happy to return to their room to undertake a personal care routine.

People's preferences, interests, likes and dislikes had been recorded and in a format that supported their individual needs.

Is it effective?

We found people's health and care needs were assessed with them, but they were not all comprehensively completed. Inconsistencies were found across some care plans that we viewed. Some care plans lacked guidance for staff to follow to ensure people's individual specific needs were met. We have asked the provider to tell us what they are going to do to meet the requirements in relation to care and welfare.

It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well.

Is it responsive?

People's needs had been assessed before they moved into the service. The registered manager told us people met with their key workers monthly to discuss their care plans as part of a system called 'resident of the day'.

People received co-ordinated care. We saw evidence in people's care plans that demonstrated people had been visited by their GP and other health care professionals. For example people's files held information and advice sought from the district nurse team in relation to their wound management care.

Is it well-led?

People that used the service and their relatives completed a satisfaction survey once a year. The registered manager told us if any concerns were raised these would be addressed promptly. Comments included: 'staff are polite and helpful and rooms are clean and tidy'. 'We are well informed by the keyworker'. 'I enjoy going out on day trips'.

Some people we spoke with were able to tell us their experience. They confirmed they felt listened to by staff and knew how to raise a complaint if they needed to.