The Ferns

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 assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a strong or proactive approach to safety. Not all significant events were fully reviewed, meaning lessons were not always learned and good practice was not consistently put in place. For example, whilst the provider reviewed accidents and incidents, where people showed distressed behaviours, there was no evidence that patterns or triggers were analysed to help understand and reduce these behaviours.

Systems were not in place to ensure risk and adverse incidents were reported to external stakeholders, including the local authority and to The Care Quality Commission (CQC). This did not ensure people were protected from the risk of harm. Leaders were not reviewing and reflecting on events within the service to reduce the risk of reoccurrence.

The provider worked with people, relatives and healthcare professionals to help keep people safe. However, they did not always make sure important information was transferred when people moved between services.

The registered manager explained that partner information was reviewed prior to care commencing. Individuals’ needs were then assessed over the initial few weeks while they remained in their original placements, to determine and agree the support required before moving to The Ferns.

However, not all relevant information was recorded and utilised by staff at The Ferns. For example, one person’s previous records showed they used picture exchange communication system (PECS) to communicate, but this was not included in their new care plan, and staff had not been trained to use this communication method. Staff were unaware this person used this tool. This meant they did not receive consistent support.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

The registered manager kept a record of safeguarding concerns raised by staff; however, they r did not understand their regulatory responsibilities to ensure incidents and events happening in the service were appropriately reported to CQC and other stakeholders. In response, the provider submitted retrospective notifications and implemented improved monitoring systems to reduce the risk of reoccurrence.

Restrictive practices, such as locking the kitchen and people’s ensuite bathrooms were taking place and were neither legally justified nor proportionate. As a result, some people were prevented from accessing areas that could have supported their independence and improved their quality of life.

We raised these concerns with the registered manager who assured us, this would be put in place.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Not all known risks had been properly assessed to keep people safe. For example, we looked at the records for one person who had a stoma bag fitted, but staff had not received the training needed to support them with this.

A stoma is a small opening on the tummy created during surgery when the bowel or bladder can’t work properly. Waste leaves the body through this opening into a special bag instead of the usual way. Staff must be trained to manage a stoma safely to prevent discomfort, infection, or other complications.

In other instances, people had assessments of risk based on their individual circumstances. One relative told us they had no concerns about their loved one’s wellbeing.

The provider detected and controlled potential risks in the care environment. They ensured that equipment, facilities, and technology supported safe care. People had adaptations in their rooms to help keep them safe. For example, for individuals who displayed distressed behaviours which could place them at risk, the environment was adapted to reduce potential harm.

People were consulted with about any adaptations made, and when changes or removals were needed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always ensure staff received the support and training they needed. The registered manger had not made sure staff completed all required training. There were gaps in key areas such as dysphagia training and Control of Substances Hazardous to Health (COSHH).

Despite this, relatives told us they felt staff knew people well, and our observations supported this. Relatives were confident their loved ones were safe.

Records showed staff were receiving regular supervision and appraisals and felt supported in their roles. However, further improvements were needed to ensure all staff received the full range of required training. However, recruitment records and staffing levels at The Ferns were sufficient.

The provider did not always assess or manage the risk of infection. Whilst the environment was generally clean and we saw staff carrying out cleaning tasks, some infection prevention and control (IPC) practices needed improvement. There were no written procedures for managing high‑risk laundry, and the provider was not undertaking IPC audits, so could not be assured about practice. The local authority IPC team had previously carried out an audit, identified required improvements, and provided an action plan. However, management had not completed the actions, and when we requested the audits, they were unaware of the outstanding work. This lack of oversight placed people at increased risk of infection.

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

Staff recorded the administration of medicines on Medicines Administration Record (MAR) charts. These records showed that people received their medicines as prescribed. However, we observed an incident involving a medicine administration error that had not been recorded. Staff informed us the medicine had been disposed of down the sink, which does not align with National Institute for Health and Care Excellence (NICE) guidance. This guidance advises that unused or expired medicines should be returned to the community pharmacy for safe disposal.

In addition, some medicines prescribed on an ‘as required’ basis did not have clear guidance or personalised protocols to support staff in knowing when to administer them. This concern was raised with management, who responded promptly to address and rectify the issue.