Fernleaf Residential Home

Updated 8 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Fernleaf Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Fernleaf Residential Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service and 3 relatives or friends about their experience of the care provided. We received feedback from 8 members of staff including the registered manager, deputy manager, care staff, housekeeping, maintenance and the activity co-ordinator. We reviewed a range of records. This included 6 people’s care records. We looked at 2 staff files in relation to recruitment. A variety of records relating to the management of the service, including audits, policies and procedures and training records were reviewed.

Updated 8 December 2023

About the service

Fernleaf Residential Home is a residential care home providing accommodation for persons who require nursing or personal care to up to 21 people. The service provides support to people living with dementia. At the time of our inspection 17 people were living at the home. The home is split over two main floors with communal areas on the ground floor and an outdoor communal space. At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person.

People’s experience of using this service and what we found

Risks were not consistently managed. Medicines and infection risks were not always managed safely.

Internal quality assurance processes were not always effective in monitoring the service which meant improvements were not always made.

People who used the service were protected from the risk of abuse, harm and neglect by suitably trained staff who knew them well. Concerns were reported and acted upon. People we spoke with told us they felt safe.

There were enough competent staff on shift to ensure people were safe and received good quality care. Staff were recruited safely; however, recruitment files needed some improvement to ensure that all steps taken were fully documented prior to a person starting at the service.

Staff were supported with an induction and rolling training programme to ensure they were skilled within their roles. Induction documentation could be improved to show all information and support provided to a new starter and training was required on supporting autistic people and people with a learning disability.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People told us the service was well-led and they received person-centred care. Relatives we spoke with supported this and told us management were open and approachable. Management and staff were clear about their roles, responsibilities and continuously looked for ways to develop and improve the service and the level of care provided.

Staff, people, and their relatives and visitors were encouraged to share their views. The registered manager understood their responsibility to be open and honest with people and had acted when things went wrong. The provider worked in partnership with others.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last CQC inspection leading to a rating for this service was good (published 22 May 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider took actions during and after the inspection visit to mitigate some of the identified risks.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fernleaf Residential Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to medicines and quality monitoring at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.