Fernlea

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Quality assurance systems were not effective when monitoring risk from incidents of distressed behaviours and risks from people’s changing health needs. Training audits failed to monitor staff training and medicine audits were not effective when monitoring the safe storage of medicines. Lessons were not learnt from the previous inspection where training and quality processes breached regulation. The provider remained in breach of regulation. Staff felt able to speak up and raise their concerns openly and they had confidence in the ability and leadership of the registered manager.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us the culture was inclusive. One staff member said, "There are regular team meetings and supervisions. The registered manager encourages us to share our concerns. They are trying to listen to all concerns." Staff told us the culture was positive, 1 staff member said "I think it’s a really good home. People receive 1:1 support when they need. We discuss any new risks all the time and discuss the best way of supporting people safely. We are a good team who care about the people living in the home." Visiting professionals told us the culture was positive and promoted people’s independence.

The provider's values of the organisation were openly displayed on the wall, and we observed staff displaying these values when speaking and interacting with people. Minutes of meetings confirmed staff were supported and could discuss their concerns openly.

The service was led by compassionate and inclusive leaders. One staff member said, "The registered manager always leads by example. They are a good manager". Another staff member said, "The registered manager is a good manager. They are very approachable person. The registered manager is regularly on the floor. They get involved and will help when needed." The registered manager provided regular support for people and staff. One staff member said, "The amount of people who knock on the registered manager’s office door is unbelievable. The registered manager will never turn people away." Visiting professionals told us the registered manager was approachable. They said, "The registered manager has an empathetic nature and has good people skills". Another visiting professional told us, "The registered manager has really good intentions, they really care about the people living in the home."

The registered manager was clear about their role and submitted notifications in accordance with regulatory requirements. The management team responded to all concerns raised in this inspection. However, the actions from the previous inspection had not been completed and we raised further concerns over incident management and overall governance.

Staff understood the whistle-blowing policy and felt confident to speak up. One staff member told us, "If I see a member of staff doing something wrong or harming someone I must speak up. I feel able to do this. The manager will listen." Another staff member said, "I am aware of the whistle blowing policy. I feel confident I could report concerns.” Staff told us the registered manager took appropriate action when they raised concerns with them. One staff member said, “The registered manager is a proactive person. I have taken concerns to the registered manager; they have always taken them seriously and acted on them. We are told not to feel scared if we have any worries or need to speak to the registered manager."

We reviewed the whistle blowing policy and staff told us where this was located.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were not always competently trained, and the provider did not take appropriate action when staff had not completed their training. This meant the provider failed to monitor staff training and ensure all staff were competent to carry out their duties safely. This placed people at risk of harm. The provider responded to all feedback and implemented new systems to improve the overall governance. We will review the success of these new systems in our next inspection.

The provider failed to ensure effective governance systems when monitoring risks to people and lessons had not been learnt following the previous inspection. During the last inspection (21 October 2022) the provider failed to ensure medicine audits were robust and they failed to ensure systems were in place to swiftly identify concerns and support staff in a timely way. This contributed to a breach in Regulation 17 (Good Governance). In response to this breach the provider completed an action plan to show how they intended to become compliant with the law. The provider failed to fully implement this action plan. This was a continued breach of Regulation 17. Governance systems were not effective when monitoring people’s health needs, such as people’s bowel movements and weights. Whilst no one was harmed the provider could not evidence actions taken when people’s health needs fluctuated. Governance systems were not effective when analysing incidents involving distressed behaviour. This meant the provider could not be assured incidents involving distressed behaviours were being managed safely and appropriate action taken, this put people at increased risk of harm. Records relating to initial assessments were not always retained. This meant the provider could not be assured all aspects of the person’s history and behaviours were assessed to ensure they were suitable to move into the home. Therefore, the provider failed to ensure people were appropriately placed. Medicine audits were taking place. However, audits did not include safe storage of medicines. Should a person require their medicines refrigerated, the provider failed to ensure this was safely monitored. We found no evidence people had been harmed. However, systems were either not in place or robust enough to demonstrate effective governance. This was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.