9 November 2023
During an inspection looking at part of 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.