CQC report explained · a residential care home
What the CQC found at Fernleaf Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely, and there were infection control, maintenance and risk-management problems. People were protected from abuse and neglect, and staffing levels were sufficient during the inspection.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Audits and checks did not identify or resolve all problems, including issues found by other organisations. The manager was described as accessible and open, but some required notifications had not been made.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found risks with medicines, infection control, premises and quality monitoring.
This was an unannounced focused inspection on 9 and 10 November 2023. Inspectors, an Expert by Experience and other inspection staff spoke with people, relatives and staff, and checked care, medicine, recruitment, training and management records.
The home was not always safe. Inspectors found missing medicine signatures, medicines without proper opening dates or authorisation, and medicine storage and checking problems. Infection control, maintenance and some risk plans also needed improvement.
The home was not always well-led. Audits had not found or dealt with all the problems, including issues raised by other organisations. The provider breached regulations about safe care and treatment and good governance.
The overall rating changed from Good at the last rating inspection, published in May 2018, to Requires Improvement. The inspection only assessed Safe and Well-led. The other question ratings were carried over from the previous inspection.
Safeguarding
Inspectors found systems to protect people from abuse and neglect. Staff knew how to raise concerns, and safeguarding referrals were made and investigated appropriately.
“Systems and processes in place protected people from the risk of abuse and neglect.” from the report
Staffing
There were enough staff on shift during the inspection. Call bells were answered promptly, and staffing was based on people's assessed needs.
“People's dependency levels were assessed by management and staffing levels were put in place to meet people's assessed needs.” from the report
Kind and person-centred care
People said they felt safe and were cared for by kind staff. Relatives said staff knew people's names and preferences.
“A relative said, "I like the fact [staff] know their residents, they know their name, they know what they like, they are not a number.” from the report
Medicines
seriousMedicine administration records had missing signatures, so it was unclear whether some people had received their prescribed medicines. Other problems included missing dates, missing authorisations, infrequent controlled-drug checks and cupboards needing maintenance.
“We found missing signatures on medicine administration records (MAR) for some medicines.” from the report
Quality monitoring
seriousThe home's audits did not identify or deal with all the problems found by inspectors. The provider had also not acted on every issue raised by other visiting organisations.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Infection control
needs fixingBathrooms, a sluice and mop storage needed updating or maintenance. Some equipment was not stored appropriately or clean.
“Mop storage and cleanliness needed improvement, other equipment, including hoists and wheelchairs, was not always stored appropriately and was not always clean.” from the report
Premises and risk plans
needs fixingThe premises needed maintenance, including lighting and a window restrictor. Inspectors also found risks involving the laundry, garden, harmful substances and a mattress setting, while some care plans lacked enough personalised detail.
“The premises needed updating. Lighting was dull in places and the premises required maintenance and improvement to reduce safety risks.” from the report
Recruitment and training records
needs fixingRecruitment files did not fully document all checks before staff started. Induction records also needed improvement, and staff needed training about supporting autistic people and people with a learning disability.
“Recruitment files needed some improvement to ensure that all steps taken were fully documented prior to a person starting at the service.” from the report
- 01What has been done to ensure every medicine administration record is complete and medicine gaps are investigated?
- 02How are liquid medicines, covert medicines and controlled drugs now checked and authorised?
- 03Which infection control and maintenance problems have been fixed, including the bathrooms, sluice, mop storage and equipment?
- 04How are audits now checking that risks, care-plan gaps and issues raised by other organisations are acted on?
- 05Has all required staff training, recruitment checking and induction documentation been completed?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the last inspection. This explanation was written from the published report of 8 December 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, February 2022
Inspected but not rated; inspectors found good infection control and safe arrangements for visits during the COVID-19 pandemic.
This was an announced, targeted inspection on 26 January 2022. Inspectors looked at infection prevention and control, and asked about staffing pressures linked to COVID-19.
Inspectors were assured that the home used personal protective equipment safely, supported testing and vaccination, managed admissions safely, and had arrangements to prevent and manage outbreaks.
People could receive visitors safely, use a visiting pod, or keep in touch through video calls and mobile phones. The home also had organised checks on testing, vaccination, protective equipment, handwashing and infection control.
The overall service was marked “Inspected but not rated”. This was not a full inspection and does not give ratings for the other areas of care.
Infection control
The home had taken practical steps to improve cleanliness and infection control, including an automatically sanitising door handle.
“The registered manager had taken an innovative approach to infection control and cleanliness, for example they had sourced a door handle that automatically sanitised hands when used.” from the report
Testing and vaccination records
There were organised systems to check that staff met COVID-19 testing and vaccination requirements.
“There were very organised systems in place to ensure staff were meeting COVID-19 testing and vaccination requirements.” from the report
Keeping families connected
People were supported to see family and friends in the home or stay in contact through video calls and phones.
“The service supported people to maintain relationships with families and friends, either by visiting within the home or via video calls.” from the report
Regular infection control checks
The home used a monthly audit to check protective equipment, handwashing and infection control procedures against current guidance.
“The registered manager had produced their own monthly COVID-19 audit to assure themselves that staff continued to meet current guidelines around PPE, handwashing and infection control procedures.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staffing pressures linked to COVID-19, and what effect do they have on care?
- 02How do you check that staff and visiting professionals meet current vaccination and testing requirements?
- 03How do you currently manage visits, including visits for people who may need extra protection from infection?
- 04How often do you audit protective equipment, handwashing and infection control, and can families see the findings?
- 05What arrangements are in place if there is an infection outbreak?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated overall. This explanation was written from the published report of 8 February 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 Fernleaf Residential Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- December 2020Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015
Registered with the Care Quality Commission on 23 January 2015.
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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