CQC report explained · a residential care home
What the CQC found at Fernbank Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found appropriate systems for staffing, risk management, medicines, infection control, fire safety and responding to incidents, although they noted minor gaps in medicine and recruitment records.
- Effective?
- Good
- This key question was not inspected during this focused visit. The report says the ratings from the previous inspection were used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The report says the ratings from the previous inspection were used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The report says the ratings from the previous inspection were used to calculate the overall rating.
- Well-led?
- Good
- Leaders had systems to monitor quality, safety and staff performance. People, relatives and staff were involved in improvements, although some relatives said there could be delays in receiving information.
What inspectors found, September 2023
Rated Good; inspectors found a safe, well-led home, but medicines and recruitment records had minor gaps.
This was a focused inspection after concerns about falls and staffing levels. Inspectors visited over two days. They observed care, spoke with people, relatives and staff, and checked care, staff and management records.
The home was rated Good for Safe and Well-led. Inspectors found suitable staffing, safeguarding, risk management, infection control and fire safety arrangements. People and relatives said the home felt safe. Leaders checked the service, responded to incidents and involved people in improvements.
There were some minor gaps in medicine records and staff recruitment files. Inspectors made recommendations about both areas. The overall Good rating also included ratings from the previous inspection for the areas not covered this time.
People felt safe
People and relatives told inspectors that the home was safe. Staff understood how to recognise and report abuse.
“People living in the home and their relatives agreed Fernbank Lodge was a safe place to live.” from the report
Person-centred support
Care records included people's preferences and histories. Staff supported people to take part in activities and family events.
“People received person-centred care. Care documentation included information about people's needs, likes, dislikes, and histories.” from the report
Learning from incidents
The provider reviewed accidents and complaints and took action to reduce the chance of similar events happening again.
“The registered manager and provider sought to learn lessons when things go wrong.” from the report
Good oversight
The provider and registered manager carried out checks and kept records of meetings, visits and quality monitoring.
“The provider also visited the home to check on the quality of care.” from the report
Medicine records
needs fixingInspectors found two recording errors. Time-sensitive medicines were given on time, but the process did not follow best practice guidance.
“People received their medicines as prescribed, although there were some minor gaps in recording.” from the report
Recruitment records
needs fixingThe provider had safe recruitment systems, but some evidence was missing from staff files. Inspectors recommended improving and keeping these records.
“The provider had systems and procedures in place to ensure staff were recruited safely, although we found minor gaps in records when checking staff files.” from the report
Updates for relatives
minorMost relatives were involved in care decisions and updates, but a couple said information was sometimes delayed.
“However, a couple of relatives said there could sometimes be a delay to them being informed.” from the report
- 01What changes have you made to medicine recording and the process for giving time-sensitive medicines?
- 02How do you now make sure every staff recruitment file contains all the required evidence?
- 03How quickly will you tell relatives about important changes or events affecting their family member?
- 04What staffing arrangements are in place at busy times, when people may otherwise have to wait?
- 05How will you monitor that the two recommendations from this inspection have been completed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection when calculating the overall rating. This explanation was written from the published report of 26 September 2023 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, December 2017
Fernbank Lodge was rated Good overall; inspectors found safe, caring and responsive support, with some records needing improvement.
The inspection was unannounced and took place on 25 October 2017. One inspector spoke with people living at the home, relatives and staff. They also reviewed care, training, recruitment and management records, observed care and checked the building.
The inspectors found that people felt safe and that staff understood their needs. Medicines, staffing, recruitment and equipment were managed safely. People received suitable food, healthcare and activities, and staff were described as kind, respectful and responsive.
The home had systems to check quality and acted on some findings. However, some quality checks were not recorded, and care records did not show people's consent. The home was given a recommendation to improve how quality audits are documented.
All five areas were rated Good. This means the inspectors found the service met the expected standards at the time of the inspection. The overall rating remained Good, as it had been in October 2015.
People felt safe
Risk assessments and care plans explained how risks should be reduced. Staff knew these instructions and followed them when inspectors observed support.
“Risk assessments were carried out to ensure risks were identified and minimised.” from the report
Kind and respectful staff
People and relatives praised staff. Inspectors saw positive relationships and staff respecting privacy before entering people's rooms.
“During the inspection we saw staff were caring.” from the report
Personalised support
People were involved in their care plans and could choose routines, meals and activities. Staff supported individual interests and requests.
“Care records we viewed confirmed people's needs were individually assessed and care plans were developed to meet their needs.” from the report
Good food and healthcare
People could have meals suited to their preferences and nutritional needs. Records showed support with healthcare appointments and follow-up information.
“People told us they were able to eat meals which met their preferences and nutritional needs.” from the report
Quality checks were not always recorded
needs fixingThe home carried out checks, but the registered manager said some medicines and other quality checks were not documented. Inspectors recommended using best practice for recording audits.
“The registered manager explained the checks were not always documented.” from the report
Consent was not shown in care records
needs fixingPeople told inspectors they had agreed to their support, but the care records checked did not show evidence of this consent. The manager said this would be addressed.
“Within the care records we viewed, we did not see evidence that people had consented to their care.” from the report
Limited instructions for some medicines
minorSome care records had limited information about when and why medicines taken when needed should be given. Staff could explain this, and the home updated the documentation before the inspection ended.
“We saw some limited information was available in care records to support staff on when and why these medicines should be administered.” from the report
- 01How do you now record and review all quality audits, including checks on medicines?
- 02How do you record each person's consent to their care and support?
- 03What written instructions are now in place for medicines given when needed?
- 04How do you decide when extra staff are needed for appointments or changes in people's needs?
- 05How are residents' activity choices and requests used to plan the activities programme?
This was an unannounced inspection of the overall quality of the care home, covering all five CQC questions and the building as well as care. This explanation was written from the published report of 1 December 2017 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 Fernbank Lodge
3 rated inspections over 8 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Goodstayed GoodSafe: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- February 2012
Registered with the Care Quality Commission on 28 February 2012.
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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
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