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 inadequate. 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 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.

In line with the provider’s policies and procedures, discussion about their vision and values took place with prospective staff at the recruitment stage and was revisited in staff meetings and supervisions. A poster explaining the vision and values was also available in the staff room. Staff told us the registered manager and all members of the management team were available to listen to them.

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.

At our last inspection we found a lack of effective and consistent management had seriously affected the quality of care provision at the service. Lack of direction and support, and heavy use of agency staff had affected staff morale. Since that time the management team had remained consistent, and the appointment of an experienced deputy had impacted the team positively. The management team had worked consistently to address issues and to make improvements. All the staff we spoke with reported significant improvements both in the quality of care for people living at the service and in the support they received. Staff told us the management team made themselves available and listened to them.

Not all of the people we spoke to were sure who the registered manager was but were positive about the management of the service. One said, “I don’t think anything can be improved”.

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

People, their relatives and staff were confident that the management team wanted to listen to their views and would act on them. As well as satisfaction surveys, the registered manager had introduced a feedback box in reception with forms for people or visitors to complete.

The provider had internal and external ‘Freedom to Speak up Guardians’ to support staff in raising issues. Staff we spoke to said they felt confident in speaking with any member of the management team.

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 employed a diverse staff team including different ethnic backgrounds and genders. Staff felt involved in the service through staff meetings and surveys and felt their opinions mattered. Outcomes of incidents, complaints, safeguarding events and assessments of the service were shared with staff to support their understanding of what was happening in the service.

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

At our last assessment we found widespread and significant shortfalls which quality management systems had not identified or addressed. Since then, the management team had worked hard to address the issues. An action plan with realistic timescales had been developed which was being systematically worked through with many of the required actions completed. Quality audit systems were in place and were being followed, however, some minor environmental issues we found, could have been identified if a robust system of daily environmental checks had been in place.

Governance systems had lacked the robust approach needed to make sure the issues with the attic ceiling were followed up. The management team had previously reported the issue to the provider’s senior maintenance management team but due to unexpected changes in the team, this had not been addressed and they were not aware of a recent fall of rubble from the ceiling into the attic space. The management team took immediate action to address this, but more robust systems were needed to make sure potentially serious issues could not be overlooked.

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.

The registered manager had established strong working relationships with health and social care professionals, local authority staff and services within the community. Feedback was positive from the local authority about how staff had worked in partnership with them.

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.

Significant improvement in all areas demonstrated the provider’s commitment to learning from feedback from a variety of sources to drive improvement within the service. Feedback from inspections was shared with all staff so they could understand why change was needed and be a part of the improvement strategy.

Information from incidents across all the provider’s services was shared with all staff to improve their knowledge and understanding and involve them in learning about how improvements could be made.