Ferndown Nursing Home

The inspection was carried out by two inspectors and a Specialist Advisor (who was a qualified nurse). An Expert by Experience made phone calls to people's relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

During the inspection we found 3 breaches of the regulations in relation to safe care and treatment, dignity and respect, and good governance. We asked the provider to submit action plans for the areas in breach of regulations.

The provider had processes and systems to assess and manage risks to people’s health and safety. However, we found the provider’s approach to assessing and managing environmental risks was inconsistent and not always effective. The safety of the premises, communal and personal spaces, and the living environment were not always effectively checked or managed to support people to stay safe.

Reviews of people’s needs and risk assessments were inconsistent, which meant people’s records were not always up to date and did not always reflect changes in circumstances. Care plans were not always updated and did not always give clear guidance for staff. This meant people were not fully involved in managing risks, and staff were not directed to provide care safely.

Medicines were not always managed safely and did not always meet people’s needs, capacities and preferences. Staff did not always follow specific instructions from the prescriber and did not label all medicines with opening dates.

We found people’s equality-related needs were not always considered and the environment was not decorated or adapted to a consistent standard to meet the needs of people living with dementia.

People felt safe and staff were aware of their responsibility to identify and report potential abuse. Staff completed safeguarding training and were confident any concerns raised would be effectively dealt with. There were enough staff to meet people’s needs, and people were supported by a consistent staff team.

People were complimentary about staff and positive relationships had been developed. However, we saw several areas of concern when on site at the Ferndown Nursing Home with regard to staff not always respecting people’s dignity and privacy.

There had been recent changes to the management structure and there was a new manager in post, who had not registered with us at the time of our inspection. Managers and staff did not share a full understanding of the risks and issues facing the service. For example, oversight and management of environmental risks was not effective. Incidents reported to the management were not always effectively scrutinised and reviewed to identify themes and trends. There was instability within the leadership of the service and there was no established management structure in place at the time of our inspection.

Governance, accountability arrangements and quality assurance systems were in place to ensure the service operated safely but were ineffective. Evidence shows the management systems were inconsistent in identifying and managing risks to the quality of the service. Audits at provider level had not identified the shortfalls found during the inspection.

All leaders were open and responsive throughout the inspection process. When we identified areas for improvement, the provider acted immediately to address any shortfalls.