This inspection took place on 23 and 24 August 2018. The first day of the inspection was unannounced.

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

We carried out this inspection over two days on 2 and 3 May 2017. The first day of the inspection was unannounced. During our last inspection in September 2016, we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We placed a condition on the provider’s registration. This required the provider, on a monthly basis, to notify the Care Quality Commission of the action being taken to address the shortfalls identified. The service was rated inadequate and placed into special measures. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

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 str

Ferfoot Care Home provides accommodation and nursing care for up to 52 people. At the time of our inspection, 45 people were resident at the home.

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 mo

The inspection team was made up of two inspectors and a pharmacist. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

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.

Ferfoot Care Home provides accommodation and personal care for up to 52 older people. At the time of our inspection 39 people were resident at the home.

This inspection took place on 15 May 2015 and was unannounced. We returned on 18 May 2015 to complete the inspection.

At the last inspection on 15 September 2014 we identified that the service was not meeting Regulations 9 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. This was because incidents and people’s food and fluid charts were not always recorded, which meant the information could not be used to identify and review people’s needs. During this inspection we saw that incidents were recorded and food and fluid charts had been completed.

The systems for assessing and managing risks did not always ensure action was taken to keep people safe. We found that risk assessments were not always completed and not always updated when people’s needs changed. We saw examples where the support people needed to manage the risk of falls and malnutrition had not been kept up to date when their needs changed.

We also found that people’s care plans were not always up to date with information about their needs and how they should be met. Some of the information we found in the care plans was not correct and did not describe the actions staff should take to provide the care people needed.

Staff provided good care and support for most of the interactions we observed. However, we saw a situation where staff did not respond promptly to a person’s request for assistance. The person had to wait for 20 minutes to use the toilet over lunchtime, during which they did not eat their main course.

There was a registered manager in post at the service. 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 and associated Regulations about how the service is run.

People who use the service and their relatives were positive about the care they received and praised the quality of the staff and management. Comments from people included, “I feel very safe here, staff will always help if you need anything” and “Staff are very kind and look after everyone very well”. People told us they felt safe when receiving care and were involved in developing their care plans. Systems were in place to protect people from abuse and harm and staff knew how to use them.

Staff understood the needs of the people they were supporting. People told us that care was provided with kindness and compassion. Most of the interactions we observed confirmed staff worked in this way. However, we also saw some staff spoke about people in ways that were not respectful and did not maintain people's privacy.

Staff were appropriately trained and skilled. They demonstrated a good understanding of their roles and responsibilities, as well as the values and philosophy of the service. The staff had completed training to ensure the care and support provided to people was safe and effective to meet their needs.

The service listened to people’s concerns and complaints and took action. One person told us, “I am able to talk to staff if there are things that need to be improved. Staff listen to me and sort out the problem”. A relative said, “I am able to speak to staff if I have any concerns and they sort things out for me. We are able to resolve most issues, but I would speak to the manager if I still had a problem”.

The management team assessed and monitored the quality of care. The service encouraged feedback from people and their relatives, which they used to make improvements.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.