Fernery House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service continued to be in breach of legal regulations in relation to safe care and treatment and staffing.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems were in place for staff to document incidents and accidents and these were individually reviewed by the service manager. However, because these were not documented on the provider’s electronic system, they were not being monitored to make sure action was taken to remedy the situation, prevent further occurrences and ensure improvements were made as a result.

The provider had started to take action to input these onto the systems, however at the time of the assessment not all had been inputted and analysed.

For example, 1 person experienced a number of incidents of self-harming behaviour. The pattern related to the reason for these incidents had not been identified, and no action had been taken to mitigate further risk of distress and injury to the person.

The lack of thorough analysis of incidents placed people at risk of being exposed to re-occurring risks.

Lessons learnt was a standard agenda item in team meetings, and we saw some evidence recorded in team meetings minutes of conversations held, for example in relation to medicine management.

The provider mostly worked well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People were being supported when they were distressed. Care plans were in place to support people to have a good day, and strategies were in place to prevent distress, however these were in the process of being reviewed, updated and transferred to an electronic care planning system. This meant not all care plans had been reviewed in line with the provider policy, and some were in paper format, while others were electronic, making them difficult to locate, navigate and follow. People receiving care and support were not given access to their care plan, although the acting manager had commenced work to change this.

Systems were in place to keep daily logs of people’s care and support; however, these were difficult to cross reference as some were incomplete and not all in 1 place.

Hospital passports were completed for people, and they had up to date health action plans in place.

Feedback from health and social care professionals was mostly positive in relation to their working relationship with the service.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Staff told us they received safeguarding training; however, we could not corroborate this with the service’s training records. Staff had knowledge of the principles of safeguarding and knew how to report any concerns.

The service maintained a record of safeguarding concerns reported by staff, however there was no information of any actions taken. While some information was captured in this after being prompted by the inspector during the assessment, the record needed to clearly evidence more robust details. For example, the reasons why a concern does not meet the criteria for reporting to the local authority safeguarding team; if a record had been made in people’s care plans and if these have been reviewed and updated. Alongside this there was no recorded immediate actions taken and how the service is reducing the risk of recurrence following an incident.

The service did not always work within the principles of the Mental Capacity Act 2005 (MCA).

Systems were in place for restrictive practice audits to be carried out, however these had not been completed for the last 2-3 years, which meant that were restrictions were in place for people, these may have not been legally justified.

The service manager has oversight of Deprivation of Liberty Safeguards (DoLS) authorisations.

People’s relatives told us that people felt safe living at the service.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some risks related to people were not always fully assessed and mitigated. For example, we observed some of the stairs in the building to be of a design which might not be easy to navigate, particularly for an ageing population. We observed 1 person while using the stairs appeared unsteady. The service did not recognise this risk, and there were no person specific risk assessments in place. There was a generic risk assessment for the stairs as part of the environmental risk assessment of the home, but this failed to address individual risks to people

There was evidence of risks related to people being assessed and mitigated, however work was still in progress to review and update these assessments and the acting manager was in the process of doing this and ensuring they all continued to provide good quality information. The risk assessments had been written but it was difficult to identify when they were reviewed and what date they needed to be reviewed.

Positive Behaviour Support (PBS) plans were in place to guide staff on how to support people at times of experiencing anxious behaviour. Although these contained good guidance for staff, these plans were not regularly reviewed and updated in line with the provider’s policy.

Staff were not always confident in providing examples of risks they support people with, such as risk related to self-harming anxious behaviour. We also observed inconsistencies in staff knowledge where people had an eating and drinking support plan in place.

Electronic care records were not comprehensive although paper records were good. Staff were replying on care documentation which had not been reviewed and updated, and although the service was working on updating this care documentation, this was in various formats, in various place. Staff were inconsistent in telling us where they would go to access people’s care documentation if they needed to refer to it. Some staff were taking guidance from agency staff, particularly in relation to 1 person, however, we found that agency staff were not always following the most recent guidance related to a specific area of that person’s support which could have had an impact on the person.

Although staff had knowledge of people’s required support, we found that International Dysphagia Diet Standardisation Initiative (IDDSI) guidance and safe eating support guidance, which was available for staff in the kitchen, were either not up to date or not in place for all people who were at risk of chocking or had eating/drinking guidelines in place. A person needed further investigation to identify the reasons for a specific risk related to eating and drinking to further mitigate the risk of choking.

We observed throughout our site visits that risks management related to food hygiene safety were not always followed by staff.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We observed the environment needed significant maintenance improvement throughout the home, including the garden. On the first visit, we discussed our concerns with the management team. At the time there was no action plan in place with timelines of when all the identified work would be completed. Following a visit from the provider’s health and safety team, we received the action plan with a timeline of when action would be completed.

While feedback was mostly positive, some observations were shared by a visiting professional in relation to the environment of the home needing an uplift and update and by a relative in relation to the poor condition of the garden.

People's rooms were personalisedto their own personal taste and interests. However, some also needed maintenance work which had been factored into the action plan mentioned above.

A relative told us; “[Relative’s] room is very personalised, it’s the smallest room and [they are] the biggest collector, makes cleaning [their] room hard which they [staff] are addressing. [Person] chose the colour of [their] room, it feels like a nice house.”

The Control of Substances Hazardous to Health (COSHH) risk assessment had not been updated since 2020. We found on all 3 days of site visits that chemicals were not locked away in the storage areas provided or the storage areas were left unlocked.

People had Personal Emergency Evacuation Plans (PEEP) in place to inform staff how to support people in case of an emergency such as a fire. A fire risk assessment had been carried out, however some actions still required completing such as replacing 2 fire and ensuring items were not stored under the stairs. The fire doors were replaced during our inspection, but we continued to observe some items being stored under the stairs during our site visits. We also observed a fire door being propped open.

Environmental checks were being carried out around the home, including fire safety checks. The service was receiving support to ensure health and safety checks and documentation were well organised and accessible.

While the provider ensured the staffing levels met the commissioned support hours for the service, they did not ensure staff were recruited safely or that they received effective support, and development.

Feedback from people’s relatives and professionals working with the service raised some concerns in relation to the use of agency staff and the effectiveness of some of the agency staff members.

The provider had not ensured all learning, development and required learning completed was monitored and appropriate action taken quickly when training requirements were not being met.

Staff told us that they received training, and we saw evidence that training was discussed in supervisions, appraisals and team meetings. However, there were gaps in refresher training such as dysphasia, fire safety, managing signs of distress, health and safety, infection control, medicine administration and nationally recognised autism training.

There were also gaps in qualifications such as the Care Certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme.

Records showed staff were receiving supervisions and appraisals and they felt supported in their role.

Improvements were needed to ensure staff were being recruited safely. This meant staff could be employed who were not safe to be supporting vulnerable people. There were gaps in recruitment checks and full employment histories were not obtained. Records were not showing that the barred list Disclosure and Barring Service (DBS) certificate had been checked and the reason for leaving and conduct in previous care roles was not consistently verified and recorded for all roles involving children or vulnerable people. This placed people at increased risk of harm.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some areas of infection prevention and control needed to be improved. There were no written procedures in place for dealing with high-risk laundry, not all Personal Protective Equipment (PPE) was available for staff who cleaned high risk areas and provide personal care to people. There was no procedure in place for the safe disposal of PPE.

We observed staff were not always following correct practices in relation to PPE usage and putting this on and taking it off.

There was a risk assessment in place, however it did not provide in-depth information to staff in relation to control measures related to cleaning of high-risk areas, dealing with high-risk laundry and contact with bodily fluids.

People’s relatives were positive about the cleanliness of the home. A relative told us; “I don’t visit often now, when I did always clean and well maintained and nice and quiet.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

When medicines were administered, they were recorded on Medicines Administration Record (MAR) charts. These showed that people received their medicines in the way prescribed for them. Improvements were needed to the way these charts were checked for accuracy each month, and new systems had been put in place to get them produced by the pharmacy in future.

If medicines were prescribed to be taken ‘when required’, there were personalised protocols to guide staff when these might be needed, and staff were knowledgeable about people’s medicines. These protocols were in the process of being reviewed with the GP surgery. Staff were aware of STOMP (an initiative to stop over-medication of people with a learning disability and autistic people).

There were suitable arrangements for ordering, storage and disposal. Storage temperatures were monitored to ensure medicines would be safe and effective. The maximum and minimum range in the medicine refrigerator was not recorded and the acting manager told us this would be monitored going forwards.

Staff had training and competency checks to make sure they gave medicines safely. However, some of these had not been updated in line with best practice guidance and the home’s policy. The acting manager was aware of this and working to get them updated as soon as possible.

Regular medicines checks and audits took place, and these helped identify issues and areas for improvement. For example, it had recently been identified that although risks for paraffin containing external preparations had been considered, risks assessments had not been recorded. We were told this was also being addressed.