Fernleigh Care Home

Updated 23 February 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 31 January 2022 and was unannounced.

Updated 23 February 2022

About the service

Fernleigh Care Home is a residential care home providing accommodation and personal care to 26 people aged 65 and over at the time of the inspection. The service can support up to 27 people accommodated over three floors.

People’s experience of using this service and what we found

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.

Risk was not always safely managed. As a result, people who had been identified as being at risk of malnutrition were at increased risk of developing health issues related to malnutrition.

The provider had quality control systems in place, however these were not always effective enough to ensure the quality and safety of the service was maintained.

The provider did not always learn lessons when things went wrong. Audits did not always identify issues and effective actions plans were not always developed or did not always result in improvements being made.

People were supported by staff who had been recruited safely, who were caring, respectful and knew people well. Staff demonstrated a good understanding of safeguarding, including the signs of abuse, and were able to describe how to report concerns.

There were enough skilled and experienced staff to meet people’s needs. Staff were adequately trained and had regular competency checks.

Effective infection prevention and control (IPC) policies and procedures were in place and the service was following best practice and Government guidance in relation to the management of COVID-19 and other infections.

People and their relatives were involved in developing and reviewing their care plans and risk assessments. People’s relatives and staff felt they were able to contribute to the development of the service.

People’s relatives and staff felt supported by the management team and provided positive feedback about the quality of communication throughout the COVID-19 pandemic.

Accidents and incidents were documented and reported on appropriately and lessons were identified and learnt from to reduce the risk of re-occurrence.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 22 January 2019).

Why we inspected

The inspection was prompted in part by notification of a specific incident, following which a person using the service died. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of falls and the environment. This inspection examined those risks.

We also received concerns in relation to medicines, infection prevention and control, staffing levels, record keeping and the management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Fernleigh Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicines and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.