This unannounced responsive comprehensive inspection took place on 30 and 31 August and 11 and 14 September 2018. This inspection was undertaken because of safeguarding concerns which had happened at the service. At our last comprehensive inspection in July 2017 the service was rated good overall and in all domains.

Fernihurst Nursing 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. They

provide care and accommodation for up to 50 people. The majority of people at this service live with dementia or have mental health needs. The service is a purpose-built care home providing accommodation over three floors, with two lifts between floors and with communal facilities on each floor. There were 46 people using the service on the first day of our inspection.

There was a new registered manager who registered with the Care Quality Commission (CQC) in February 2018. They had previously worked as the deputy manager at the home. A registered manager is a person who has registered with CQC 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.

Staff and relatives said at times the staff levels at the service were too low. The provider had a system in place to assess people’s dependency to determine the number of staff and range of skills required in order to meet people’s needs. During the inspection people were wandering in and out of other’s rooms. This was normalised behaviour at the home and action was not being taken by staff to try and prevent this. The provider increased the staff levels during the inspection.

People were placed at risk because of poor staff response times to call bells. This posed a risk to people because when pressure mats were activated setting off an alarm by people wandering into other’s rooms. There was confusion at the service about which people required regular checks. The provider took action to address this concern.

There was not a robust system at the service to ascertain if staff were responding to call bells promptly. During the inspection process the call bell system was serviced to ensure it was working correctly. The management team held a staff meeting and made staff aware of concerns found at the inspection which included call bell response times and that call bells would be monitored.

Staff did not always have the information they needed to support people with complex behavioural needs receiving emergency one to one support. Staff were not ensuring they stayed with people requiring one to one support at all times. This posed a risk to the person, others and staff. The registered manager and regional manager took action regarding these concerns.

The provider was not always ensuring people were protected against the risk of abuse. There had been a delay on two occasions of the management team informing the local authority safeguarding team of safeguarding concerns. This placed people at risk of further abuse. The management team were working with the local authority safeguarding teams regarding these concerns and to mitigate further risks.

Improvements were needed to the way people’s medicines were managed and recorded. Medicines were not always administered or recorded correctly. Some people’s medicine administration records (MARs) had one or more gaps for regularly prescribed medicines where it was not clear of a dose had been given or not. It was not possible to be sure if peoples’ external products were being applied in the way prescribed for them. Medicines had not been re-ordered in a timely way to prevent people’s doses being missed.

The provider had quality assurance processes in place

Fernihurst Nursing Home provides care and accommodation for up to 50 people. The majority of people at this service living with dementia or have mental health needs. The service is a purpose built care home providing accommodation over three floors, with lifts between floors and with communal facilities on each floor. There were 48 people using the service on the first day of our inspection.

At the last inspection in July 2015, the service was rated Good. At this inspection we found the service remained Good.

There was a 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.

Relatives and staff gave us positive feedback about the management team. They said they were open, friendly and welcoming. They were happy to approach them if they had a concern and were confident that actions would be taken if required. The registered manager and deputy manager were very visible at the service and had an open door policy. They promoted a strong, caring and supportive approach to staff and put a high emphasis on staff training and increasing their knowledge.

There were sufficient numbers of suitable staff to keep people safe and meet their needs. The registered manager was using two dependency tools to assess they had sufficient staff and that they were deployed in the right areas of the home.

The staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (2005) (MCA). Where people lacked capacity, mental capacity assessments were completed and best interest decisions made in line with the MCA.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. They had made appropriate applications for people they had assessed that required to be deprived of their liberty to the local authority DoLS team.

People were supported by staff who had the required recruitment checks in place and were trained and had the skills and knowledge to meet their needs. Staff had received a full induction and were knowledgeable about the signs of abuse and how to report concerns.

Improvements were made during the inspection to ensure monitoring checks were regularly made to people in their rooms and recorded. Systems were also put in place so the nurses and management team formally monitored that the monitoring forms were being completed.

People were supported to maintain a balanced diet. We discussed that not all people had drinks available in their rooms. Action was taken to address this. People and visitors were positive about the food at the service.

People received their prescribed medicines on time and in a safe way. Visitors said staff treated their relative with dignity and respect at all times in a caring and compassionate way.

People were supported to follow their interests and take part in social activities. A designated activities coordinator was employed by the provider. They ensured each person at the service had the opportunity to take part in activities and social events which were of an interest to them.

Risk assessments were undertaken for people to ensure their health needs were identified. Care plans reflected people’s needs and gave staff clear guidance about how to support them safely. Care plans were person centred and people where able, and their families had been involved in their development. Staff were very good at ensuring people where able were involved in making decisions and planning their own care on a day to day basis. People were referred promptly to health care services when required and received

Summary

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 49 people living at Fernihurst Nursing Home.

The summary is based on our observations during the inspection. We spoke with six people using the service, the acting manager, deputy manager and nine staff supporting them. In addition we spoke to five agency staff working at the home supporting people who required one to one support.

We also spoke to four visitors at the home and a doctor who visited the home most weeks to undertake a review of their patients. We asked their views about the care people received.

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

Is the service safe?

The acting manager ensured there were staff on duty with the appropriate qualifications, skills and experience required to ensure people’s needs were met. People were supported by staff who had received appropriate training in the skills required to perform their roles.

The acting manager understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty safeguards (DoLS). The manager had made an application to the local safeguarding deprivation of liberties team. This meant that the home had needed to deprive somebody living at the home of their liberties. We saw that the home had acted in line with Deprivation of Liberty Safeguards legislation (DoLS). This legislation protects people’s rights when they are unable to make decisions about their own welfare.

A visiting GP told us that he had seen improvements at the home, he felt well informed regarding changes to his patients and that the home had followed guidance and instructions that he had given.

The home had suitable arrangements in place to reduce the risks of people receiving inadequate nutrition or becoming dehydrated.

The home was clean and had processes in place to maintain a hygienic environment.

Is the service effective?

People’s health and care needs were assessed and their care plans and assessments were reviewed monthly. Specialist dietary, mobility and equipment needs had been identified in people's care plans where required. This showed that people were having care delivered effectively or in accordance with their assessed needs.

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 the service caring?

People were supported by staff who were understanding and sensitive to their needs. We saw that staff showed patience and gave reassurance and encouragement when supporting people. We saw that people living at the home appeared comfortable with positive body language in the company of the staff. This told us that staff took the time to understand and communicate with people despite their disability.

Visitors told us that they had no concerns about the home “I feel happy I can go home and have no worries he is being looked after wonderfully” and “I am always contacted if there are any changes they keep me informed”.

Is the service responsive?

The home had appropriate systems in place for gathering, recording and evaluating information about the quality and safety of the overall service. Systems were in place to make sure the acting manager and provider learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

People knew how to make a complaint if they were unhappy. Complaints that had been received since our last inspection had been acted upon promptly and in line with the homes complaints policy and procedure. The home also had a comments book for people to record concerns when they visited the home. People can therefore be assured that the home acts upon complaints, they are investigated and action is taken as necessary.

Is the service well-led?

The provider Sanctuary Care had put in place an experienced acting manager temporarily from their higher management team while the registered manager was absent from the home. This meant that the provider had ensured the home was managed by a competent person in the absence of the registered manager.

The provider undertook a monthly compliance visit. This showed that they worked with the acting manager, deputy manager and the staff to ensure the standards that people expected at the home were maintained.

The home worked well with other agencies and services to make sure people received their care in a joined up way.

People living at the home with the support of relatives and friends were being asked to complete an annual satisfaction survey for 2014. We were told that the information gathered would be collated and where there were shortfalls or concerns raised these would be addressed. This helped to ensure that people received a good quality service at all times.

We the Care Quality Commission (CQC) inspected Fernihurst following concerns that we received. Concerns included medication errors being made, staffing levels being too low and care and welfare of residents being compromised. At this inspection we found that the home met all of the Health and Social Care Act Regulations that we looked at. We did not find evidence that supported the concerns raised.

People experienced care and support that met their assessed needs. We saw that people who lived at the home took part in a variety of activities. One person told us “Yes, I’m happy here. They (the staff) do a good job”, “There is always something going on” and “they are always very helpful”.

The home had reported a significant medicines error to the local safeguarding team. The safeguarding team were satisfied with the actions taken by the home. We found that the home had taken appropriate actions in relation to this incident. The manager explained that the homes medicines management systems required some improvements and we found that they had a plan in place to do this.

There were enough qualified, skilled and experienced staff to meet people’s needs at the time of this inspection visit. The home was using a high number of agency staff however they had contracts with the agencies in order to provider regular staff. We saw evidence that the home was advertising for permanent staff.

This inspection was undertaken in response to issues of concern which had been reported to us. The concerns were about staffing levels and the risk of people’s assessed health and social care needs not always being met. We found the concerns were substantiated.

People that we spoke with made positive comments about the way they were looked after; "I am very satisfied with the way I am looked after", "I get the help I need, but sometimes have to wait for staff to be available to help me" and "the staff are angels."

However, we saw some incidents of people acting aggressively to others who lived at the home. Staff told us that there were not enough staff to meet the mental health needs of people living at the home or to spend quality time with people. We saw that there were not enough staff to respond to the assessed needs of some people's during our inspection.

We (the Commission) visited Fernihurst Nursing Home to check that the service had met the compliance actions, which were made at the last inspection in October 2011.

Two inspectors visited over the course of one day on 9 May 2012. The majority of people living at Fernihurst had profound communication difficulties or dementia. We introduced ourselves to people and we met and spoke with three visitors. We looked closely at the care offered to four people living at Fernihurst to help us make a judgment about the quality of care provided. We looked at their care records, met with them and observed the care delivered to them. We also spoke with five staff members about the people’s needs and about how these were met.

Those people who could speak with us, and those relatives we spoke with, said that staff were kind and helpful and we saw that people were comfortable in the company of staff. We saw staff being kind and respectful and saw that they tried to help people to make choices.

Comments made by the relatives of people living at Fernihurst included “Couldn’t get better care”, “I am more than happy with the care provided. [My relative] is well looked after”,” Well looked after and I have peace of mind” and “We can visit whenever we like”.

We (the Commission) visited Fernihurst Nursing Home as part of the planned schedule of visits. Two inspectors visited over one day. Although the majority of people living here had profound communication difficulties or dementia, we introduced ourselves to people and we met and spoke with two visitors. We looked closely at the care offered to four people living here. This is called pathway tracking and helps us to make a judgment about the quality of care provided. We looked at their care records, met with them and observed the care delivered to them, spoke with staff about their needs and about how these are met.

Those people who could speak with us, and those relatives we spoke with, said that staff were kind and helpful and we observed that people were comfortable in the company of staff. Some people wished there were more staff on duty, and this included some staff we spoke with. We observed staff being kind and respectful and saw that staff tried to help people to make choices. We found that the home was clean and well cared for, demonstrating that staff showed respect for people by respecting and caring for the environment in which they live.

We found that some important decisions were being made for people, and staff were allowing some people to make important decisions, without completing Mental Capacity Act assessments and best interest decision making records. These decisions included 'do not resuscitate' instructions, the provision of personal care by three members of staff whilst the person resisted and the giving of covert (hidden) medicines.

There was a low incidence of pressure sores in this home and the majority of people were maintaining or gaining weight. However, we also saw that some individual needs were not being addressed sufficiently well to reduce risks to people's health and welfare. This included staff not exploring the food likes and dislikes of one person who was losing weight. Records relating to one very dependent person showed that they were not always being supported to drink and that they were not having all their care needs met. Mental health care plans lacked detail and this was leaving some people at risk of not having these needs met.

Staff had a good understanding of what abuse is and what to do if they suspected this was occurring. They were also familiar with whistle blowing policies and said that they would be confident to use these if needed. The risk of harm to people from other residents was not being managed adequately, and some people were at risk from the actions of others. In addition, the recruitment of staff was not robust enough to ensure that people were cared for by appropriate staff.

This organisation has many quality assurance processes in place. In some cases these had shown that improvements were needed. However, these improvements were not always made.

We carried out an unannounced comprehensive inspection on 2 and 3 July 2015. Fernihurst Nursing Home provides care and accommodation for up to 50 people. The majority of people at this service have dementia or mental health needs. The service is a purpose built care home providing accommodation over three floors, with lifts between floors and with communal facilities on each floor. There were 47 people using the service on the first day of our inspection. We last inspected the service in April 2014, at that inspection the service was meeting all of the regulations inspected.

There was a 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.

Everyone gave us positive feedback about the registered manager. They said they were happy to approach her if they had a concern and were confident that actions would be taken if required. The registered manager was very visible at the service and undertook an active role. They promoted a strong caring and supportive approach to staff as they felt this was then the culture in which staff cared for people at the service.

The registered manager had recognised that people’s needs had increased at the service and had put in place additional care staff to meet people’s needs. This meant there were sufficient numbers of suitable staff to keep people safe and meet their needs.

The provider demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (2005). Where people lacked capacity, mental capacity assessments were completed and best interest decisions made in line with the MCA.

People were supported by staff who had the required recruitment checks in place, were trained and had the skills and knowledge to meet their needs. Staff had received a full induction and were knowledgeable about the signs of abuse and how to report concerns.

People were supported to eat and drink enough and maintained a balanced diet. People and visitors were positive about the food at the service. People were seen to be enjoying the food they received during the inspection.

People received their prescribed medicines on time and in a safe way. Visitors said staff treated their relatives with dignity and respect at all times in a caring and compassionate way.

People were supported to follow their interests and take part in social activities. A designated activity person was employed by the provider and worked with staff to assess each person at the service. This was so they could ensure activities were set at an appropriate level and meaningful to the person.

Risk assessments were undertaken for people to ensure their health needs were identified. Care plans reflected people’s needs and gave staff clear guidance about how to support them safely. They were personalised and people where able and their families had been involved in their development. People were involved in making decisions and planning their own care on a day to day basis. They were referred promptly to health care services when required and received on-going healthcare support.

The premises were well managed to keep people safe. There were emergency plans in place to protect people in the event of a fire or emergency.

The provider had a quality monitoring system at the service. The provider actively sought the views of people, their relatives and staff. There was a complaints procedure in place and the registered manager had responded to concerns appropriately.