Fernside Hall Care 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.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance at the service.

This service scored 32 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider’s statement of purpose set out the aims and objectives for the service to ensure people had positive experiences and received high quality care. However, leaders and staff failed to ensure these standards were implemented. There was a lack of oversight to ensure people were supported appropriately and engaged in a way that was meaningful to them. Concerns found during the assessment relating to person-centred care had not been identified by the provider. This was reflective of the culture at the service. Restrictive practices were accepted and went unchallenged with no consideration being given to the impact this may have on the lives of the people involved.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There was a lack of effective and consistent management of the service which had impacted on the quality of people's care and had a detrimental impact on staff. There had been 3 changes in the management of the service over the previous 18 months. The current manager had been in post since October 2024 and had applied for registration with CQC. People, relatives and staff spoke positively about the new manager. One person said, “[Manager] knows what I enjoy doing and encourages me to do it.”

There was a lack of management oversight and direction of staff. For example, discussions with staff and our observations identified not all staff attended handovers and therefore missed important information and updates about people’s care. Walkie talkies were available to enable staff to communicate with each other when working in different areas, but some staff did not use them.

Quality assurance processes were limited and not robustly implemented. We found significant concerns during our inspection, some of which reflected a lack of compassion and inclusivity in the approach of the leadership team. For example, restrictions on people’s liberty of movement and people exposed to the risk of harm or injury due to bed rails not being used safely. The impact of such shortfalls on people’s lives went unrecognised.

People did not always feel they could speak up and that their voice would be heard.

Staff were aware of the whistleblowing policy, although they were not always clear about the process. Whilst we found the polices were available to staff, knowledge of whistleblowing had not been embedded into the culture.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse staff team including different ethnic backgrounds and genders. There was evidence of some staff meetings and supervisions to show staff were included in decision making. However, improvements were required to ensure equity in how agency staff working in the service were viewed and treated. For example, an agency chef on their first shift in the service received no handover or information about menus or meals when they arrived on duty. It was not clear if information displayed in the kitchen about people’s dietary needs was up to date so they asked staff who said no one was on a special diet, which was not correct.

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.

Effective systems and processes were not in place to assess, monitor, improve and sustain the quality and safety of the service. Quality audit systems were not effective in ensuring improvements were made and sustained. Issues were identified but it was not clear if actions had been completed. Provider oversight of the service was not robust and failed to take action to address issues identified and make improvements.

Our assessment found widespread and significant shortfalls which quality management systems had not identified or addressed. We identified regulatory breaches relating to medicines, infection prevention and control, person-centred care, safeguarding people from abuse and improper treatment and assessing, monitoring and mitigating risks to people's safety.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

A lack of oversight and monitoring at the service impacted the effectiveness of collaborative working and sharing of information, as learning and quality improvement was not routinely taking place. People’s care plans were not always up to date, detailed and accurate therefore we could not be assured partnership working was always fully supporting effective care.

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

There were not effective systems in place to ensure continuous learning and improvement at the service. Our assessment found widespread and significant shortfalls which the provider had not identified and addressed through their quality management systems. Safety issues we raised on our first site visit day had still not been fully addressed when we returned on our third site visit day. We requested and received an action plan from the provider which showed they had started to address some of the issues we raised during the assessment.