Fernsby Brookes Limited

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.

This is the first assessment for this service. This key question has been rated 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 71 (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.

The management team supported an open culture and had created a strong team ethos. Staff spoke positively about working at the service and felt well supported in their roles. One staff member told us, “The management team are good, we work as a collective team.”

Processes to involve people and staff in developing the culture included seeking people's feedback through telephone calls, meetings and questionnaires on the quality of care and service provided. Where suggestions were made, action was taken.

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.

People and relatives knew who the management team were, and how to contact them. One person told us, “Yes, I know who the managers are and it’s really easy to contact them.” One relative told us, “The company is well managed and organised,” another relative said, “I would recommend this service. With my hand on my heart, I would say the staff are wonderful.”

Staff understood their roles and responsibilities and told us they felt supported by the management team. One staff member said, “I find the management team to be supportive."

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

Staff felt confident to raise any issues or concerns with the management team if needed. One staff member told us, “I feel able to raise any concerns with the managers and believe they would act on them straight away.” Another staff member said, “We work together as a team and support each other.”

The provider also held regular team meetings, where staff had the opportunity to raise concerns and offer suggestions. The nominated individual understood the need to be open and honest when things went wrong in line with their responsibilities under the duty of candour.

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 they felt included in decisions about the service and enjoyed their job. One staff member told us, “We are encouraged to offer our ideas,” another said, “It’s important to speak up for the clients about any changes they want from us.”

All staff had received equality and diversity training. The provider’s policies promoted equality and diversity, and a diverse staff team has been recruited to support people using the service.

The service had clear responsibilities, roles, systems of accountability and overall good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Systems and processes were in place to monitor the quality and safety of the service. This included audits of care records, staff competencies and checks on the environment. However, we identified medicines audits and checks were not always effective as they failed to identify some of the issues we found. For example, PRN protocols were not in place for all medicines prescribed ‘as and when required’ to provide staff with clear guidance on the safe administration of these prescribed medicines and creams.

Despite these shortfalls, which were addressed during our inspection, the management team demonstrated a commitment to ensure the improvements made were sustained to ensure people consistently received good care and achieved good outcomes.

The nominated individual demonstrated an understanding of the regulations and their responsibilities. They had informed us about important events within the service for example, management arrangements in place to cover the absence of a registered manager.

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.

Staff worked in partnership with health and social care professionals to ensure people had the best outcomes for their health and wellbeing. People and relatives confirmed this. One person said, “The manager rings me every 3 to 4 weeks to check I am happy with everything and I am ok."

The provider 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. They actively contributed to safe, effective practice and research.

Staff felt supported by the provider and spoke about opportunities available for their personal development. One staff member told us, “I felt my induction was good, I felt confident to start doing the calls on my own once I had completed this.”

Staff recorded incidents and accidents. These were reviewed by the management team and action taken to prevent reoccurrence. Any lessons learnt were discussed in team meetings.