CQC report explained · a residential care home
What the CQC found at Ferncroft
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing, recruitment, risk management, medicines and infection control were found to be safe.
- Effective?
- Good
- People received personalised support from trained staff. Their health, nutrition, communication, independence and legal decision-making needs were addressed.
- Caring?
- Good
- This question was not inspected during this focused visit, so the current report does not provide a new rating.
- Responsive?
- Good
- This question was not inspected during this focused visit, so the current report does not provide a new rating.
- Well-led?
- Requires improvement
- Management was visible and approachable, but governance systems had not always ensured that best practice and legal reporting requirements were followed.
What inspectors found, July 2023
Rated Good overall; inspectors found safe and effective care, but well-led was Requires Improvement because governance checks had missed safety and reporting issues.
This was an unannounced, focused inspection on 12 June 2023. One inspector met the four people using the home, spoke with staff and a relative, and checked care records, medicines, staffing, training and management records.
Safe and effective were rated Good. Inspectors found enough trained staff, personalised care plans, safe medicines processes, good safeguarding practice and support for people's health, choices and independence.
Well-led was rated Requires Improvement. Governance checks had not identified unsuitable window restrictors or the failure to notify CQC about the outcome of DoLS authorisations. The provider took prompt action after the inspection.
The overall rating remains Good. The previous overall rating was also Good, while the effective rating improved from Requires Improvement to Good. This visit did not inspect caring or responsive.
Safeguarding
Staff knew people well and understood how to protect them from abuse. The service also worked with other agencies when needed.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Staffing
There were enough staff to meet people's needs, including support for activities and visits. Recruitment checks were also in place.
“The service had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted.” from the report
Personalised support
Care plans reflected people's needs, communication, sensory needs, strengths and aspirations. People and those important to them were involved in reviewing their support.
“People had care and support plans that were personalised, holistic, strengths-based and reflected their needs and aspirations, included physical and mental health needs.” from the report
Improved staff training
Staff were up to date with mandatory training and received regular supervision and appraisals. This was an improvement since the previous inspection.
“Following our last inspection staff were now up to date with their mandatory training.” from the report
Choice and independence
People were supported to make choices, manage some risks and develop daily living skills. They could personalise their rooms and take part in meal planning and cooking.
“People were involved in managing risks to themselves and in taking decisions about how to keep safe.” from the report
Window safety
needs fixingThe first-floor window restrictors were not in line with best practice when inspectors visited. The manager later provided evidence that suitable restrictors had been installed.
“At the time of our inspection whilst the windows on the first floor were restricted these restrictors were not in line with best practice.” from the report
Missed legal notification
needs fixingThe manager had not told CQC about the outcome of DoLS authorisations as legally required. The report says this was addressed after the inspection.
“The registered manager had not notified CQC as legally required of the outcome of DoLS authorisations.” from the report
Governance oversight
needs fixingManagement checks did not always identify whether processes followed best practice and legal requirements. Updated audits and action plans were in place before the inspection.
“Governance systems did not always ensure that all processes were in line with best practice and that all regulatory and legislative requirements were adhered to.” from the report
- 01What evidence can you show that the first-floor window restrictors now meet the relevant best practice requirements?
- 02Have all DoLS outcomes now been notified to CQC, and how do you check that future notifications are made on time?
- 03What changes have been made to governance audits since the inspection, and who checks that actions are completed?
- 04What is the current position on the caring and responsive areas, which were not inspected during this visit?
- 05How do people and their relatives take part in reviewing and improving their support?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the overall rating used the previous ratings for those areas. This explanation was written from the published report of 7 July 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, September 2019
Rated Good overall; inspectors found safe, kind and personalised care, but staff training and supervision needed improvement.
This was an unannounced inspection on 12 August 2019. The inspector spoke with people living at the home, staff, relatives and managers. They observed care and medicines being given, and checked care records, medicines records, recruitment files, training records and quality checks.
The home was rated Good overall. Safe, caring, responsive and well-led were rated Good. Inspectors found people were protected from abuse, received their medicines safely, had personalised care plans and were treated with kindness and respect.
Effective was rated Requires Improvement. Some staff training had not been refreshed on time, and some staff had received too little supervision. The home also needed improvements to communal decoration and to some quality checks. Managers accepted these points and said they had plans to address them.
Safe medicines
Medicines were stored, given, recorded and checked safely. Inspectors found no unexplained gaps in the medicines records.
“People's medicines were stored, administered, recorded and audited appropriately.” from the report
Kind and respectful care
People and relatives said staff were kind. Inspectors observed trust between people and staff and found that people's dignity and privacy were respected.
“Staff treated people with care and kindness.” from the report
Personalised support
Care plans included people's health needs, life histories, preferences and goals. Staff supported people to make choices and take part in activities they enjoyed.
“Care plans were personalised and contained information relating to people's physical, emotional and mental health needs.” from the report
Communication and involvement
Staff understood different ways people communicated, including non-verbal communication. People and relatives were involved in decisions about care where needed.
“Staff had a good understanding of the AIS and people's communication needs were assessed and documented within their care plans.” from the report
Training not refreshed
needs fixingSome staff training, including health and safety and first aid, had not been refreshed as required by the provider's policy. Inspectors said this might mean staff were not up to date with best practice and new legislation.
“Training records showed that training had not been refreshed as required by the provider for all staff.” from the report
Infrequent supervision
needs fixingSome staff had only one supervision session in the previous year. The records were brief, so it was difficult to see what had been discussed.
“When we looked at the records we saw some staff had only one supervision session in the last year.” from the report
Communal areas needed refurbishment
minorInspectors and relatives noted that shared areas needed new decoration and refurbishment to make the home feel warmer and more homely.
“Communal areas of the house were in need of new decorations and refurbishment.” from the report
Quality checks did not identify all improvements
needs fixingQuality assurance systems were in place, but they did not always identify issues such as décor and staff training and support soon enough.
“Quality assurance systems were in place however they did always identify areas where improvements were necessary” from the report
- 01Which staff training was overdue at the inspection, and has all of it now been refreshed?
- 02How often are staff now receiving supervision, and how is each session recorded?
- 03What refurbishment has been completed in the communal areas since the inspection?
- 04How does the home check that its quality assurance system identifies issues with training, supervision and the environment?
- 05How are people and relatives involved in decisions about activities, care plans and any refurbishment?
This was a planned, unannounced inspection covering all five CQC key questions and the overall quality and safety of the care home. This explanation was written from the published report of 11 September 2019 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 Ferncroft
4 rated inspections over 8 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Goodstayed GoodSafe: GoodEffective: Requires improvementWell-led: Good
- February 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 22 November 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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