Fernleigh 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 assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were supported and involved in improving the service and told us considered they worked well as a team. The registered manager supported staff to understand the aim of the service, which was to deliver good care which met people’s needs and promoted their rights.

Staff told us the provider and registered manager promoted teamworking. Comments we received included, “We all want people to have the best experiences they can,” and, “People come first, last and every in-between here.”

The registered manager was known to people and spent time with people if this was what people wanted. One person shared, “[Registered manager] is really nice, she always talks to me.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider employed a registered manager who worked with other stakeholders, people and relatives to shape the service and deliver care.

Staff spoke positively about the management team. Staff said they felt supported, and they were able to discuss any concerns they had with them. One staff member said, “If I need any guidance [registered manager] is always available.” Another staff member shared, “[Registered manager] takes our concerns and acts on them. A relative commented they were confident the registered manager would be available if needed and a further relative said of the registered manager, “She has always been extremely approachable, responsive and supportive.”

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

A member of the management team were available 24 hours a day. There was an on-call system where staff could contact a member of the management team if advice was needed. Staff told us they were confident to speak up and believed appropriate action would be taken. Information on how to speak up was on display and accessible.

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.

The provider had a supportive culture which valued staff. Staff told us they felt supported and were confident the registered manager and provider promoted inclusion and equity. Staff could give examples of how their individuality was recognised and their rights upheld. One staff member shared how adjustments had been made to their working pattern in response to personal commitments. There were regular ‘tasting evenings’ where staff cooked foods from their own culture for people and other staff, in addition religious festivals were recognised and celebrated. This promoted inclusion and upheld staff and people’s diversity and rights.

The provider had clear responsibilities, roles, systems of accountability and good governance.They used these to manage and deliver good quality, sustainable care, treatment and support.They acted on the best information about risk, performance and outcomes, and shared thissecurely with others when appropriate.

Audits, feedback and surveys identified shortfalls and improvements were made. For example, attendance at staff meetings was monitored to help ensure staff remained up to date with changes and a door had been identified as needing repair and this was actioned. This helped drive improvements at Fernleigh House.

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

improvement.

The registered manager worked with external stakeholders to improve the service. They shared information promptly and supported shared decision making which placed people at the centre of their care. A visiting health professional shared that staff were passionate in their role and worked closely with them to act on recommendations and advice, to improve the service provided.

Care records recorded the involvement of health professionals and how the advice given would be acted upon. Records also showed if further changes were required, relevant health professionals were informed and guidance was sought.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Fernleigh House demonstrated an exceptional commitment to learning, continuous improvement and innovation. The service had achieved Autism Accreditation from the National Autistic Society, an externally recognised quality standard which evidences excellence in autism support and person-centred practice. Leaders used this achievement to drive further improvement. The registered manager actively contributed to peer reviews across the provider’s other services, sharing expertise, celebrating success and supporting the spread of best practice across the organisation.

People were meaningfully involved in influencing and shaping how the service operated. One person participated in a ‘Lived Experience Group’, working alongside representatives from other services to review policies, procedures and organisational processes. Their feedback directly informed changes to documentation and communication methods, ensuring information was more accessible and responsive to different communication styles. This demonstrated the provider’s commitment to co-production and valuing the expertise of people with lived experience.

The provider showed innovation in promoting effective communication. A member of staff had been enabled to undertake specific training and become a Communication Champion within the home. They provided colleagues with guidance on how to support individuals with communication needs. Recommendations from health professionals were acted upon swiftly and developed into personalised communication plans. This proactive approach enabled people to express their views, make choices and participate more fully in day-to-day life, leading to improved outcomes and quality of life.

The provider had created a strong learning culture where information, ideas and best practice were actively shared. Regular team meetings, reflective discussions and organisation-wide learning forums ensured staff benefited from lessons learned both within Fernleigh House and across other services. Staff described feeling engaged in improvement initiatives and understood how changes in practice had been implemented as a result of shared learning. This promoted a culture where improvement was continuous rather than reactive.

Audit processes were followed and results were analysed to identify what worked well and where there were shortfalls. Data from audits, feedback, incidents and outcomes were analysed to identify trends, celebrate good practice and inform service improvements.

Staff told us they were informed of any changes and supported to implement these when required.