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
- Inspectors found systems to protect people from abuse, assess risks, manage medicines, recruit suitable staff and prevent infection. A window restrictor was missing from an upper-floor utility room during the visit, but the provider confirmed the work was completed afterwards.
- Effective?
- Good
- People's needs were assessed before moving in. Staff were trained and supported, consent was recorded, and people were supported with food, health appointments and their individual needs.
- Caring?
- Good
- Inspectors observed respectful and attentive care. People and relatives said staff were caring, and people were involved in decisions about their care and daily lives.
- Responsive?
- Good
- Care plans included people's preferences, communication needs, interests and goals. People were supported to keep relationships, attend activities and day centres, and have their end of life wishes recorded.
- Well-led?
- Good
- The provider had improved repairs, audits and care records after the previous inspection. Inspectors noted some missing confirmation that monthly care plan reviews had taken place, which managers said was part of ongoing work.
What inspectors found, December 2022
Rated Good; inspectors found safe, kind and personalised care, with some records still being completed.
This was an unannounced follow-up inspection on 23 November 2022. One inspector observed care, spoke with people, relatives, staff and managers, and checked care plans, risk assessments, medicines, infection control and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines, suitable training, personalised care and support with health, food, activities and community life.
The home had improved since the previous inspection, when it was rated Requires Improvement and breached regulations about the premises and good governance. Repairs and window restrictors had been added, end of life wishes were recorded, and the previous breaches were no longer present.
Inspectors noted a small amount of work still in progress. At the inspection, one upper-floor utility room window did not yet have a restrictor, although this was completed afterwards. Some care plans also lacked confirmation that monthly reviews had taken place.
Improved safety
The provider repaired damaged areas and fitted window restrictors after the previous inspection. Other building, gas, water and fire safety checks were also in place.
“Fire safety doors and damaged areas within the home, such as skirting boards and door frames had also been repaired, since our last inspection.” from the report
Safe medicines
Inspectors found medicines were given as prescribed, records were completed and staff had training and competency checks.
“People's medicines were managed safely. They told us they received their medicines when required.” from the report
Kind and respectful care
Staff were observed treating people respectfully and protecting their privacy during personal care. People and relatives described positive relationships with staff.
“During our inspection we observed staff were attentive to people and treated them with respect.” from the report
Personalised activities
People had individual activity plans and were supported to follow hobbies, attend day centres, go for walks and maintain relationships.
“Each person had their own individual weekly activity plan.” from the report
End of life planning
The home acted on the previous recommendation. People's wishes were discussed, recorded in care plans and supported by staff training.
“People's wishes for end of life care and support were explored and respected in the event of changes in their health.” from the report
One window safety measure was outstanding
minorAt the inspection, a window in an upper-floor utility room still lacked a restrictor. The provider confirmed after the inspection that this had been completed.
“a utility room on the upper floor of the home in which there was a window still had not been fitted with a window restrictor.” from the report
Some care plan review records were incomplete
minorInspectors found some care plans did not confirm that monthly reviews had taken place. The manager said this was part of ongoing actions.
“people's care plans contained some missing information, such as confirmation they had been reviewed each month.” from the report
- 01Can you show us how every person's monthly care plan review is recorded and checked?
- 02Can you confirm that all window restrictors and other repairs identified at the previous inspection remain safe and maintained?
- 03How are safeguarding concerns, including allegations involving staff, investigated and used to improve practice?
- 04How will you make sure each person's cultural, communication, activity and end of life preferences continue to be followed?
- 05How is the registered manager supported while managing two services?
This was an unannounced follow-up inspection covering all five CQC key questions and infection prevention and control, after the previous rating and reported concerns. This explanation was written from the published report of 22 December 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, January 2022
Rated Requires Improvement; inspectors found kind and personalised care, but safety checks, repairs, records and planning needed stronger management.
This was the first inspection since the service registered under the new provider. One inspector visited without notice on 14 December 2021. They spoke with people living at the home, staff, the manager, the provider and relatives. They also checked care plans, risk assessments, medicines, staffing, infection control and management records.
People told inspectors they felt safe and were treated kindly. Staff supported people to make choices, stay independent, access healthcare and take part in activities. Care was personalised, communication needs were considered, and medicines and staffing were managed safely.
However, some upper-floor windows could be opened fully because restrictors were missing. A bedroom door did not shut properly, there were holes in skirting, and some consent records were incomplete. The home had not explored people's wishes about end of life care. Its quality checks had not found these problems, and there had been several managers in the previous 18 months.
The overall rating was Requires Improvement. Effective and Caring were rated Good. Safe, Responsive and Well-led were rated Requires Improvement. The provider confirmed after the inspection that window restrictors had been fitted and repairs and other improvements had been made.
Kind, respectful support
People and relatives described staff as caring and respectful. Inspectors saw positive relationships and a relaxed atmosphere.
“People were well treated. Staff were kind and respectful towards people.” from the report
Personalised care
Care plans included people's interests, preferences and goals. Staff used this information to support people in ways that suited them.
“Care and support plans were person-centred and provided a background to the person and a brief history of their needs” from the report
Safe medicines and staffing
Inspectors found enough staff and saw medicines being stored, given and recorded safely. Staff had medicines training and checks of their competence.
“People received their medicines safely and on time.” from the report
Choice and community activities
People were supported to choose their activities, maintain relationships and access the local community. The home had improved its activity programme.
“People followed their own interests and hobbies and they were supported with these.” from the report
Training and health support
Staff received training and support. People were helped to eat and drink well and attend appointments with health professionals.
“People were supported to maintain their health and receive any treatment they needed from healthcare services” from the report
Unsafe windows and repairs
seriousLarge upper-floor windows had no restrictors, creating a potential risk of serious injury. A bedroom door did not close fully and damaged skirting also needed repair.
“There were large windows in people's rooms on the upper floor that people could open fully because there were no window restrictors in place.” from the report
Management checks missed risks
seriousThe provider's quality checks did not identify the missing window restrictors, fire door problem, incomplete records or lack of end of life planning. Inspectors also noted that a fire risk assessment due in 2020 had not been confirmed.
“This meant the provider was not effectively assessing the safety and quality of the home.” from the report
Incomplete consent records
needs fixingSome records did not show whether people had consented to specific parts of their care. The manager said these records would be completed.
“Some of these individual consent records were left incomplete.” from the report
No end of life planning
needs fixingThe home had not discussed people's end of life wishes or recorded their preferences, including cultural or religious requirements. Inspectors recommended following best guidance.
“There were no systems in place for people's end of life support needs to be taken into account” from the report
Inconsistent leadership
needs fixingThere had been a number of managers over the previous 18 months. The report says this affected the consistency of leadership, although a new manager was in post.
“This meant there was a lack of consistent leadership to maintain the standard of the home.” from the report
- 01Have window restrictors now been fitted to every relevant window, and how are they checked regularly?
- 02Has the bedroom door been repaired so it closes fully, and have all damaged skirting and doorways been repaired?
- 03When was the home's fire risk assessment last completed, and what actions did it identify?
- 04How are consent decisions recorded now, including whether each person has agreed to specific parts of their care?
- 05How will you discuss and record each person's end of life wishes, including cultural or religious preferences?
This was an unannounced planned inspection covering all five key questions and infection prevention and control; it was the first inspection since the service registered under the new provider. This explanation was written from the published report of 22 January 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.
Every inspection of Fern Leaf Carehome Limited
4 rated inspections over 6 years: the service has held its Good rating throughout.
- December 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017GoodSafe: Requires improvementEffective: 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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