Fernlea

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

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 requires improvement. At this assessment the rating has changed to 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 75 (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.

Relatives told us the registered manager was open, transparent, and approachable. They felt confident that any concerns raised would be listened to and addressed promptly. This contributed to a positive relationship between families and staff at the service.

The registered manager and deputy manager promoted a positive culture of care in which staff felt valued. Staff felt able to give feedback and raise concerns. Staff told us they were approachable and available to offer support, and they took time to check in with them regularly and provided guidance not only in their professional roles but also showed care and understanding on a personal level.

The registered manager actively worked in partnership with external professionals and agencies, this ensured people received well-coordinated and effective care. Staff told us they valued these relationships, which supported better outcomes for people and ensured their needs were met in a timely and responsive manner.

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.

Relatives told us the registered manager and deputy manager were approachable, supportive, kind and responsive to any questions or concerns they raised. A relative told us, “The door is always open, and any concern would be taken seriously, but I haven’t had to raise any concerns.”

Staff told us they felt valued supported and treated fairly by the management team. The registered manager and deputy manager were visible in the service. Staff told us they were approachable and supportive and took a genuine interest in what people relatives and staff had to say. All staff we spoke to said they felt valued one staff told us, “I love coming to work I feel we are really making a difference and it is a lovely environment to work in.”

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

Staff told us they were well supported by the registered manager and the deputy manager and felt confident that any concerns raised would be taken seriously and acted upon appropriately.
Staff described the management as approachable and responsive. One staff member said, “We are encouraged to speak to the [registered manger] and [deputy manager] if we had any concerns.”

Staff said they would have no hesitation in escalating concerns externally, including to the local authority or the Care Quality Commission (CQC), if they felt issues were not being addressed internally.

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.

Staff told us that wellbeing was regularly discussed during supervisions, and they felt well supported by the management team both professionally and with any personal concerns. The staff team came from a variety of diverse cultural backgrounds, and everyone we spoke with said they felt comfortable and welcomed within the service. Staff consistently reported that they felt listened to, valued and cared for by the management team.

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 this securely with others when appropriate.

There were regular checks and audits in place to monitor the quality and safety of the service. Medicine management audits were completed regularly. Health records, including fluid intake, bowel movements and weight records, were maintained consistently and used to identify changes in people’s health and wellbeing, with appropriate actions taken.

Incidents were recorded clearly, with analysis undertaken, actions identified, and outcomes monitored. Staff understood their individual responsibilities to care and support people safely. They knew how to recognise, and report concerns and were confident in their duty to document issues accurately and escalate them when needed. This contributed to a culture of safety, transparency, and accountability throughout the service.

There was evidence of learning and reflection, including discussion of incidents and learning points during staff meetings and handovers,

Systems were in place to monitor training compliance and ensure staff remained competent in their roles.

The registered manager notified CQC of all significant events in a timely manner, in line with statutory requirements.

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.

Relatives told us they were invited to participate in care reviews and were kept informed of any changes made by professionals involved in their family member’s care. One relative told us, “We did the care plan together it is very person centred.”

One professional told us “The whole team’s willingness to learn new skills and adapt their approach when new individuals are admitted. [Staff member} has worked exceptionally on supporting the care planning for a person I am involved in. Another professional told us “Staff go above and beyond to ensure they care for [person’s name] they are very compassionate, professional and engaging. Professionals told us the staff team sought professional input as issues arose and have adapted well to meet the needs of people.

Records demonstrated regular collaboration with a range of health and social care professionals.

The management team focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Professionals told us staff are willing to learn to improve the outcomes for the people at the service.

People, relatives, staff and professionals were encouraged to contribute ideas for continuous improvement. Staff told us they were regularly updated about the outcomes of audits, incidents, accidents, and safeguarding concerns. They felt valued and engaged in the improvement process and confirmed that lessons learned were shared openly. This contributed to a culture of reflection, shared learning, and service enhancement.

As part of its ongoing digital transformation strategy, the provider has introduced a new digital care system. This replaced paper records which will improve the accuracy of care records and audits, strengthening oversight and monitoring.

The provider demonstrated a clear and ongoing commitment to learning, improvement, and the delivery of good quality care.