Fernery House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
At our last inspection we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to good governance.

This service scored 50 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider did not always take timely action in response to risks and concerns or prioritise safe good quality care and improvements were not always sustained.

We did not identify a consistent culture of learning and improvement. Actions identified from the audits which were carried out were not completed without delay, some action had been in progress for a long time and others re-identified without further escalation.

A provider representative told us they were hoping things would have be better by July 2025 when staffing settled but this had not been the case.

Staff shared with us that that the changes in management over the last couple of years had made them unsure of what they were expected to do as each manager came in with fresh ideas which they did not get time to embed.

A relative told us; “There are changes, staff supervising evening and weekend can’t give a very accurate picture, new staff in supervisory roles not carers. Changes in manager, [former registered manager] moved on I was impressed with [them] at a higher level than ordinary. [Acting manager] is a good permanent member. [They are] the assistant manager, good continuity and covers frequent changes of manager.”

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

At the time of the assessment there was no registered manager in place. The service was overseen by the deputy manager who stepped up to be the acting manager. They started to be supported by a senior support worker; however this staff member was new in post and had to be inducted in the role by the acting manager.

The acting manager had a large backlog of actions to address, most of which were historical. They were aware of what needed to be addressed in the service, the amount of work it involved and the workload they had to complete and was communicating this to the provider. However, at the time of the inspection, they were carrying out this work alongside the day to day running of the service which was challenging.

Provider audits had not been sufficiently robust in identifying some of the concerns we found or by providing an analysis and oversight of progress of actions to ensure the necessary steps were put in place to reduce risks and improve the quality of care.

We found the acting manager to have a good knowledge of learning disabilities. They demonstrated empathy through the language and descriptors they used. They showed compassion with how they described people living at the service and appeared to have a good value base when they spoke of people and called them “People they supported and worked with.” They also had a good knowledge of a person’s narrative relating to their care and support.

Feedback from people’s relatives was positive in relation to the current acting manager, however they shared views in relation to the new management structure the provider was implementing and how this might impact on what is provided.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had policies and process in place to support staff in raising concerns. They also provided staff with information about how concerns can be escalated.

Staff told us they felt listened to when raising concerns to the service’s management team.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

People were being supported by a diverse staff team. Staff told us they felt supported and did not share any concerns about the way they were treated.

Policies and procedures were in place to support staff in their role. Despite records being inconsistent, Equality and Diversity training was made available to staff and some confirmed they completed this.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

The provider had not made or sustained significant improvements and did not have an effective system in place to monitor the quality of care and drive improvements.

The provider’s audits and checks identified areas of improvement. However, actions continued to not be effectively addressed nor appropriate action taken without delay where progress was not achieved as expected. These included areas such as incident and accident analysis, review of mental capacity assessments and care documentation, health and safety, the environment people lived in and oversight of staff training.

Audits carried out were not effective in identifying some of the concerns we found during the inspection. For example, we identified concerns in relation to infection prevention control, person-centred care, records, restrictive practices, analysis of safeguarding concerns and safe recruitment. These concerns and failure to take timely actions in relation to these placed people at prolonged risk of increased harm.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

In the main, health and social care professionals provided positive feedback about how they worked with the service. There was evidence of joint working with professionals, accessing health support for people when required and referrals being made.

People were accessing the local town and amenities; some being supported with wider and more person-centred engagement than others.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Governance and quality assurance systems had not demonstrated sustained improvement.

At the last inspection of the service, CQC found the service to be in breach of 4 legal regulations. At this inspection, the inspection team had identified that the provider failed to fully embed and sustain their action plan to ensure they met the regulation in all areas of improvement previously identified.

While some improvements were noted during this inspection, the service continued to be in breach of all 4 legal regulations identified at the previous inspection and an additional breach was identified at this inspection.