Fern Lodge

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 inspection of this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion. The provider’s organisational values were in alignment with CQC’s ‘Right support, right care, right culture’ guidance. However, at the time of assessment, leaders could not fully demonstrate how they worked with people, their representatives and staff to build a culture focused on enabling and empowering people to achieve their own goals and aspirations.The previous manager had left the service in October 2024, and a new manager had been in post since February 2025. Whilst there was continued oversight of Fern Lodge, we received feedback some relatives felt communication with the service had not been as strong in this time. For example, 1 person’s relative said, “[Management] are a bit elusive at times, this is down to the interim part of it. I hope to be told a manager is in post and we can communicate more and more.” Plans were already in place to enhance communication with relatives, to support fully personalised care planning. The new manager was in the process of registering with the CQC, and had also introduced a staff charter, setting the provider’s shared values of ‘Care, Innovation and Compassion’.

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. They did so with integrity, openness and honesty. However, whilst there had been an interim team in post some areas of governance and oversight had not been as effectively managed at location level. For example, under previous management, statutory notifications had not been made to the CQC as required in relation to people’s Deprivation of Liberty Safeguard (DoLS) assessment outcomes. Leaders acted on our feedback during the inspection and ensured statutory notifications were made retrospectively. The management team were aware of issues and priorities within the service, and were working towards improvements and changes to systems and processes. The service was open to inspection feedback and to driving continuous improvement. The new manager told us, “I want to do the best I can.” However, more time was required to show the impact of their work.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Whistleblowing posters were on display in the service, so staff knew how to raise any issues or concerns if required. A professional who worked with the service told us, “Management often work in the numbers to role model and provide continuity of care and good practice at all levels.” A staff member told us, “The manager is the best manager I have ever had in a care home. I can ask her, and she will let me know what to do and how to do it. It’s very open door.”

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 received training in equality and diversity. Regular staff meetings took place to support all staff to feel included. A staff member told us, “At the last meeting there was ‘Employee of the month’ which went to [colleague] because of their thorough documentation. [Managers] make sure we know that they value our opinion.”

The provider had clear responsibilities, roles, and systems of accountability and good governance. This enabled them to act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had a robust centralised system which reviewed the number of incidents, harm levels, safeguarding matters, compliments and complaints, and training compliance on a quality dashboard. However, as the service was still using paper documentation, there were some areas at the location level which had not been fully fed back to the provider as part of this governance cycle. For example, it was unclear how lower-level paper-based ABC records fed into wider incident analysis, and we found some gaps in audits of paper care plans which did not identify the need for reviews. The provider had already invested in new electronic systems for the service, to aid consistency and oversight going forwards.

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. A professional told us, “The adults living there have done so for a number of years and we haven’t been made aware of any concerns following reviews taking place.” Another professional told us, “[Fern Lodge] is very good at reaching out to us, and taking our advice.”

The provider focussed on continuous learning, innovation and improvement across the organisation and local system. They actively contributed to safe, effective practice and research. However, more work was required to encourage creative ways of delivering equality of experience, outcome and quality of life for people. Plans were in place to enhance engagement with people and their representatives, to continuously improve the service. This still needed to be fully implemented, embedded and monitored. Relatives said, “We have not been involved in surveys yet” and “Not received a newsletter, which would be great. We don’t know other [people], it would be nice to see their photos and names, it would be nice to have one (a newsletter) 6 monthly.” The provider told us surveys were sent out annually. Additionally, a new newsletter had just been introduced at the time of our inspection.