CQC report explained · a residential care home
What the CQC found at Fernleigh Care 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
- Inspectors were assured about most infection control measures. They were only somewhat assured because vaccination checks for staff and visiting professionals were not properly recorded or checked at first.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2022
Fernleigh Care Home was inspected but not rated; inspectors found good visiting arrangements but gaps in checking vaccination records.
This was an unannounced, targeted inspection on 31 January 2022. It focused on infection prevention and control during the COVID-19 pandemic, and asked about staffing pressures.
The home supported visits in several ways, including in-person visits, a visiting pod, telephone and video calls. Visitors were screened for symptoms, asked for a negative lateral flow test and given protective equipment.
Inspectors were assured about most infection control arrangements, including protective equipment, testing, admissions, social distancing, cleanliness and visiting guidance. However, they were only somewhat assured that vaccination checks for staff and visiting professionals were being managed effectively.
The service was inspected but not rated. This means the report does not give a Good, Requires improvement or other overall quality rating, and it was not a full assessment of all aspects of care.
Flexible visiting
The home offered several ways for people to keep in touch with relatives, including visits in the home, a visiting pod and remote contact.
“People received visits in a variety of ways. These included visits in the service, visiting pod and contact via telephone and video calls.” from the report
Support for essential caregivers
Essential caregivers were supported to provide continuity for people living in the home.
“Essential caregivers were supported to provide continuity of care to people.” from the report
Protective measures
Visitors were screened for COVID-19 symptoms, asked for a negative lateral flow test and given protective equipment.
“Visitors were screened for symptoms of COVID-19 and evidenced a negative Lateral Flow Device (LFD) test prior to the prior to the visit taking place, they were also provided with Personal Protective Equipment (PPE).” from the report
Vaccination checks
needs fixingAt the time of inspection, the home had not checked the vaccination status of visiting professionals before entry and had no record of staff vaccinations. New systems were put in place during the inspection.
“The vaccination status of professionals deployed to the care home was not checked prior to entry and there was no record of staff vaccinations.” from the report
- 01How do you now check and record the COVID-19 vaccination status of staff and visiting professionals before they enter?
- 02How do you make sure the new vaccination-checking systems continue to be followed?
- 03What infection control arrangements are currently in place for visitors, including symptom screening, lateral flow testing and protective equipment?
- 04How are visits currently provided, including in-person visits, visiting-pod visits and telephone or video calls?
- 05Have staffing pressures affected people living in the home, and what measures are in place to manage them?
This was an unannounced targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it did not provide a full rating of the service. This explanation was written from the published report of 23 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.
What inspectors found, November 2021
Rated Requires Improvement; inspectors found unsafe medicines management and weak checks on quality and risks.
This was an unannounced focused inspection on 22 September 2021. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
The home was not always safe. Some medicines were not managed correctly, including as-needed medicines, medicine records and storage. Checks on people's weight were also missing, including for people at risk of malnutrition.
The home was not always well-led. Audits and action plans did not reliably find problems or make sure they were fixed. The overall rating fell from Good to Requires Improvement. The other three question ratings were carried over from the previous comprehensive inspection because they were not inspected this time.
Caring and respectful staff
Staff were described as caring and respectful. They knew people well and understood their individual needs and risks.
“People were supported by staff who had been recruited safely, who were caring, respectful and knew people well.” from the report
Staffing and training
Inspectors found enough skilled and experienced staff. Staff had training and regular checks of their competence.
“There were enough skilled and experienced staff to meet people's needs.” from the report
Infection control
The home was following infection control procedures and government guidance for COVID-19 and other infections.
“Effective infection prevention and control (IPC) policies and procedures were in place and the service was following best practice and Government guidance” from the report
Safeguarding
Staff understood how to recognise and report abuse. Safeguarding referrals had been made promptly when needed.
“Staff demonstrated awareness of safeguarding and whistle-blowing procedures and were able to describe how to safeguard vulnerable people.” from the report
Family involvement
People, relatives and staff were involved in care planning and giving feedback. The home used video calls and newsletters to keep relatives informed during the pandemic.
“The registered manager developed alternative methods of communicating with people's relatives when they were unable to visit.” from the report
Medicines were not always safe
seriousAs-needed medicines were not always supported by clear instructions or given according to those instructions. Medicine records were incomplete and some creams were left where they could be accessed.
“Medicines were not always safely managed. As a result, people were at increased risk of receiving medicines not in line with the prescriber's instructions.” from the report
Nutrition risks were not monitored
seriousSome people's weights had not been recorded for several months. This included a person identified as being at risk of malnutrition.
“This person's weight had never been recorded.” from the report
Weak quality checks
needs fixingAudits did not identify known medicines problems. Action plans were missing or were not completed promptly, so the provider did not show that it was learning from earlier concerns.
“The provider did not respond in a timely manner to issues identified by partnership agencies.” from the report
Privacy in the shower room
needs fixingA first-floor shower room was overlooked and its upper windows were not opaque. There were no curtains or blinds to protect people's privacy.
“There were no curtains or blinds to protect people's privacy and dignity.” from the report
- 01What changes have been made to ensure as-needed medicines are given only when needed and recorded correctly?
- 02How do you now check medicine records, storage and stock levels, and who reviews those checks?
- 03How are people at risk of malnutrition weighed and monitored, including when someone refuses to be weighed?
- 04What action has been taken to make the first-floor shower room private?
- 05What is the current action plan following the two breaches, and how do you check that every action is completed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 6 November 2021 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 Fernleigh Care Home
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2021Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodWell-led: Good
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
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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