Ferndown Nursing Home

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 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.

The service was in breach of legal regulation in relation to the governance at the service and management oversight.

This service scored 57 (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 provider’s vision and culture were shared with staff in the staff handbook and residents in the service users guide. All staff worked in collaboration to ensure a quality service for the people. The manager ensured staff delivered care in line with those values during regular spot checks and supervision sessions. The management team operated an ‘open door’ policy where people, relatives and staff could speak to them at any time to ensure there was an open culture where concerns could be raised and acted upon.

People, relatives and staff told us the home was well managed and described leaders as approachable. They described the home as having a culture that valued openness and respect. Relatives told us the manager was “responsive”, “very friendly”, “excellent and very approachable.” A member of staff told us, “It is a lovely home with a caring and dedicated team who genuinely want the best for the residents.”

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. However, leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The provider had recently implemented a new management structure in the service. There was no registered manager in post at the time of our inspection. A new manager had been appointed in November 2025, and they intended to apply for their registration. A clinical lead post had been made redundant and clinical oversight was provided by the clinical director overseeing a few other care homes in the area. There was instability within the leadership of the service and the management structure in place was not fully established at the time of our inspection.

Staff told us the home went through a period of instability due to recent changes. They told us there was lack of clinical leadership presence in the home. Comments included, “We just need a clinical lead nurse." However, we received overwhelmingly positive feedback from staff about the new manager. Staff described the manager as “approachable”, “supportive” and “visible on the floor” with a hands-on approach and actively supporting staff. Staff told us they had confidence in the new manager to drive improvements. Comments included, ”Over the last few years, the home has gone through some changes, which have not necessarily been beneficial. However, with [manager’s name] leadership and support, positive steps are being taken. I am confident we can continue to make improvements and build on the progress being made.”

The manager had a good understanding of their regulatory responsibilities, including notifying CQC as required. However, managers and staff had not always shared a full understanding of the risks and issues facing the service. For example, monitoring of daily care delivery or oversight of comprehensive care planning and needs assessments by the managers was unreliable or inconsistent. We raised this with the provider, and they decided to reinstate the clinical lead post and commenced recruitment immediately.

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

A whistleblowing policy was in place; this included the key principles of freedom to speak up. There was a positive culture of speaking up where staff felt confident to actively raise concerns and those who did (including external whistleblowers) were supported, without fear of detriment.

Leaders promoted transparency and were receptive to challenge, ensuring concerns were listened to and acted upon. The manager told us they promoted openness through an open-door approach and regular opportunities for discussion. Staff said they were aware of the whistleblowing policy and would feel comfortable to raise concerns directly with the management team. Staff described feeling confident to share feedback and report poor practice without fear of negative consequences.

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 an equal opportunities and equality and diversity policy. People were supported by a diverse workforce from different cultures and backgrounds. Leaders supported work towards an inclusive and fair culture by improving equality and equity in the team and ensuring equality of opportunity and experience for the workforce within their place of work, and throughout their employment. All staff who responded to our feedback request, felt they were treated fairly and with respect.

The manager engaged with staff to involve them with the running of the service. They had an open-door policy, staff meetings, and worked alongside staff so they could speak openly. Staff morale was high, and staff spoke positively about how they worked as a team and were supported. Comments from staff included, “The management team are approachable and supportive. They are visible within the home and willing to listen to staff concerns and suggestions” and “We have a good team of staff who work hard to support both the residents and each other, and we do our best to create a positive environment for everyone.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance, management and accountability arrangements were unreliable and inconsistent. Systems for identifying, capturing and managing organisational risks and issues were not effective, and not all legal requirements were fully understood by leaders. Systems were not regularly reviewed. Quality assurance systems did not operate effectively in helping to ensure people consistently received safe and good quality care and support. For example, various health and safety audits and checks were completed however they didn’t identify concerns relating to the environmental risks. This meant people were at increased risk of harm from environmental hazards which were not identified and risk mitigation measures not implemented.

Also, we found no evidence of provider’s oversight of behavioural monitoring reports or administration of medicines used to control behaviours prescribed as ‘when required’ in times of distress. This meant opportunities were missed to identify trends and patterns of behaviours and to establish person-centred approach that detail specific triggers, ensure alternative non-pharmacological interventions were attempted first, and exact symptoms justifying the use of medicines to control behaviours. We discussed this with the manager and they and took immediate action and intended to implement monthly monitoring of behavioural charts in corelation of administration of medicines used to control behaviours through auditing.

The provider took immediate action and implemented various additional audits and improvements to quality assurance systems. We will assess the effectiveness of the improvements implemented at the next inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, they did not always effectively and consistently share information and learning with partners or collaborate for improvement.

Staff and leaders did not always consistently engage with people, communities, and partners to share learning with each other that resulted in continuous improvements to the service. These networks were not consistently used to identify new or innovative ideas that could lead to better outcomes for people.

We received negative feedback from 2 healthcare partners about collaboration and joined up working with the service. Partners commented on difficulties in communication which could potentially lead to delays in treatment. Comments included, “We have experienced some communication issues causing frustration and confusion in the past. There has been a slight improvement recently.”

Efforts had been made by the provider to foster more positive relationships. The manager recognised the need for more collaborative partnership working to drive improvements. For example, meetings with local GP surgery and frailty team were arranged to establish more effective and open communication, helping to ensure people’s needs were understood and met in a timely way.We will assess the effectiveness of the improvements implemented at the next inspection.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Quality assurance arrangements were not always effective or applied consistently to ensure continued learning and improvements. Concerns were investigated and incidents were scrutinised by the manager. Lessons were shared and acted on. However, some investigations lacked the full rigour needed and the learning was not always applied inconsistently. Managers actively encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. However, the culture of reflective practice and collective problem-solving was not fully embedded. Staf and leaders had not consistently demonstrated a good understanding of how to make improvement happen. The approach was inconsistent and had not always included measuring outcomes and impact. This meant opportunities to identify shortfalls and drive improvement, and development were not always seized.

Improvements were not always identified, and where they were, action was not always taken or identified shortfalls were not always rectified in a timely way and lessons learnt had not always been effectively shared with all staff to prevent re-occurrence. Improvements were not fully embedded and sustained in practice. For example, we found staff lacked full understanding and awareness of how to support people after they had an unwitnessed fall or with a risk of skin integrity breakdown. This had placed people at risk of not having their care needs identified or risks of harm identified to prevent a re-occurrence.