CQC report explained · a residential care home
What the CQC found at Fern Leaf Carehome Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks were assessed, medicines were administered safely and there were enough staff, although medicine storage temperature checks needed improvement.
- Effective?
- Good
- Staff were trained and supported. People received suitable food, help with health appointments and support to make decisions, although one pre-admission assessment lacked detail about personal choices and cultural needs.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People and relatives were involved in decisions about care, and independence was encouraged.
- Responsive?
- Good
- Care plans reflected people's histories, preferences, interests and communication needs. People were supported with activities, relationships, complaints and contact with their communities.
- Well-led?
- Good
- The manager and staff understood their roles and used checks and audits to monitor the service. Inspectors found an open culture, good communication and positive feedback, alongside minor inconsistencies in some records.
What inspectors found, March 2022
Fern Leaf Carehome Limited was rated Good overall; inspectors found kind, personalised care, with medicine storage monitoring to improve.
The inspection was unannounced and took place on 24 February 2022. One inspector spoke with people living in the home, staff, the manager, the provider and a relative. They reviewed care plans, risk assessments, medicines records, infection control records and management documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were supported to make choices, stay independent, use local services and keep in touch with family and friends.
Inspectors found enough trained staff, safe recruitment, suitable care planning and good support with food and health appointments. Staff were described as kind, respectful and supportive.
There was one recommendation about checking the temperature where medicines were stored because the cabinet was near a window and could be exposed to strong sunlight. Inspectors also found some minor errors and missing review dates in care records.
Personalised support
Care plans included people's histories, preferences, interests and communication needs. People had choice and control over their care.
“People received care and support that was personalised for their needs.” from the report
Kind and respectful staff
People and relatives described staff as kind, caring and respectful. Inspectors saw staff spending time with people and supporting their independence.
“People told us the staff were kind and caring.” from the report
Community and relationships
People were supported to attend college and local activities, follow their interests and maintain contact with family and friends.
“People were supported to maintain relationships with family and friends to avoid social isolation.” from the report
Staffing and training
There were enough staff, and recruitment checks were completed. Staff received induction, training, supervision and appraisals.
“Training was provided to staff to give them the skills to provide support to people safely and effectively.” from the report
Good leadership
The home had quality checks covering medicines, care plans, infection control and the building. People, relatives and staff gave positive feedback.
“The registered manager maintained audits and checks of medicine records, care plans, infection control processes and carried out environmental checks of the building.” from the report
Medicine storage temperature
needs fixingThe medicine cabinet was near a window and could be exposed to direct sunlight. The room and cabinet temperature was not being checked, so inspectors recommended monitoring this.
“The temperature of the room and of the medicine cabinet was not checked as part of medicine storage procedures.” from the report
Some care record errors
minorSome care plans and risk assessments had missing review dates, typing mistakes or other small errors. Inspectors asked the manager to review and correct them.
“We noted some minor inconsistencies in some of the information in care plans and risk assessments.” from the report
Limited detail in one assessment
minorOne pre-admission assessment contained basic information and did not record the person's choices, wishes or cultural needs. The provider had developed a more detailed template for future use.
“However, the assessment contained basic information and did not highlight the person's personal choices, wishes or any cultural needs.” from the report
- 01How do you now check and record the temperature of the medicine room and cabinet?
- 02What changes have been made to the pre-admission assessment process to record personal choices, wishes and cultural needs?
- 03Have the missing review dates, typing mistakes and other errors in care records been corrected?
- 04How will you make sure care plans continue to reflect each person's interests, communication needs and independence goals?
- 05How are relatives kept involved in care reviews and informed about changes to visiting arrangements?
This was a planned, unannounced inspection that assessed all five key questions and included a review of infection prevention and control measures; the previous inspection was targeted and not rated. This explanation was written from the published report of 31 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2020
Fern Leaf Carehome Limited: inspectors found people safe and management arrangements in place, but accident forms were not easy to access and no rating was given.
This was a targeted inspection on 11 September 2020. One inspector spoke with two people, two relatives, the manager and staff. They checked care records, risk assessments, recruitment files and management records.
Inspectors looked only at specific concerns about safety and leadership. They found people were protected from abuse, risk assessments were in place, staffing levels were sufficient and recruitment checks had been completed. The home also had infection control arrangements, including access to COVID-19 testing and appropriate protective equipment.
There was a process for reporting accidents and incidents, but the forms were not easy for staff to access. Inspectors also noted that feedback surveys had not yet been collected under the new provider arrangements.
The service was inspected but not rated. This means the inspection did not assess the full Safe or Well-led questions, so it did not change the previous rating.
People felt safe
People and relatives told inspectors that people were safe. Staff understood how to recognise and report abuse.
“People were safe from the risk of abuse. People told us they felt safe.” from the report
Enough staff
Inspectors saw the required number of staff on duty. People, relatives and staff said staffing levels were sufficient.
“We saw the required number of staff on duty at our inspection.” from the report
Clear risk guidance
Risk assessments covered areas such as choking, nutrition and mobility. Staff had clear instructions to reduce identified risks.
“This type of guidance helped staff monitor and mitigate risks to people's health.” from the report
Support for independence
The home supported people to make choices, take part in activities and develop skills that could increase their independence.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Infection control
The home had procedures for infection prevention, including COVID-19. Inspectors were assured that protective equipment was being used safely.
“We were assured that the provider was using personal protective equipment (PPE) effectively and safely.” from the report
Incident forms were difficult to access
needs fixingThe home had a process for reporting accidents and incidents, but staff could not easily access the forms they needed. The manager agreed to make paper and electronic versions easier to find and use.
“We were assured procedures were in place for incident reporting, but we found the necessary forms staff were required to complete were not easily accessible.” from the report
Feedback had not yet been collected
minorThe new provider had not yet obtained questionnaires or survey feedback from people and relatives. The manager said these would be sent out in the following months.
“Feedback from people and relatives via questionnaires and surveys had yet to be obtained under the new provider arrangements.” from the report
- 01How can staff access accident and incident forms on every shift?
- 02What changes have been made to the paper and electronic filing systems for incident reports?
- 03How do you collect and act on feedback from people and relatives now?
- 04Who is responsible for the home when the registered manager is not on site?
- 05How often are each person's risk assessments reviewed, and what happens when their needs change?
This was a targeted inspection of specific concerns about Safe and Well-led; neither question was rated and the full five key questions were not assessed. This explanation was written from the published report of 22 October 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Fern Leaf Carehome Limited
2 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- August 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2020
Registered with the Care Quality Commission on 20 March 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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