Ferncross Residential Home

Medicines had improved and were being managed more safely. However, the management of prescribed creams did not follow best practice and the provider took immediate action to improve their safe storage. Medicines audits were in place however, they now appeared to be overcomplicated. Improvements had been made to the processes to manage risks and people were supported by staff who knew the help people needed to promote their safety. However, we found some elements of risk management had not been recognised. A new accident and incident recording system was in place and these events are now being regularly recorded. However, the oversight of all incidents was not being consistently recorded, audited or analysed. Improvements had been made to the environment since the last inspection and the service is no longer in breach of regulation. An ongoing plan is in place for repair, refurbishment and fire safety of the premises. Regular safety checks are now in place. We found some specific equipment in use had no systems in place for regular checks. New processes had been implemented to ensure staff were recruited safely and the service is no longer in breach of regulation. However, checking systems that had been put in place had not been consistently completed and no audits checks on the files were completed. Enough suitably qualified, competent, skilled and experienced staff were not always deployed effectively we found a breach of the legal regulation 18. Staffing levels seemed at times to be insufficient. We saw a range of different staff behaviours, skills and knowledge demonstrated especially when supporting people with dementia. Staff had received a variety of training which was predominantly completed online. Systems were in place to protect people from abuse and harm. People were supported to have choice and control and where relevant they and their relatives were involved in planning their care. People lived in a clean environment.

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. The provider for this location is also the registered manager. Daily they were leading and managing the service and had since the last inspection following which they had introduced new processes and was driving improvements. Improvements had been made across the safety of the service. However, the processes for assessing risk, safety monitoring and service improvement were not always consistent and/or effective and we found a breach of regulation relating to good governance. We were not assured that the governance systems used were effective in identifying how the service could improve.

At our last inspection we recommended the provider/registered manager acquainted themselves with legislative requirements as they related to health and social care. At this inspection we noted there were still some gaps in their knowledge of the requirements. Following accidents and incidents in the home the processes in place did not allow for identifying lessons to be learned and then shared with staff on a regular basis. Staff morale at the service was good. Staff spoke about the provider positively and felt they were treated fairly and had the freedom to speak up.