The Ferns Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained required improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the safe management of people’s health care needs, infection control processes and the general care environment.

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Lessons learned from accidents and incidents had been recorded but were not embedded in to practise, this meant people remained at risk from preventable incidents. Where training had taken place staff did not demonstrate what they had learnt consistently, for example, when using hoists to move people.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People had access to a range of health and social care professionals when needed. Records were in place to support handovers between services.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Safeguarding issues were shared with the local authority, however, actions which were put in place to maintain people’s safety following incidents were not always embedded. The management had not identified these issues prior to the inspection.

Staff had undertaken safeguarding training and knew how to report safeguarding incidents.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had been carried out but some people’s assessments were not routinely followed to mitigate the identified risk. For example, where regular checks were required, these were not being carried out at the required intervals.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The care environment was unclean and worn, some equipment was damaged and continued to be used. Rooms which were identified as being ready for new occupants were visibly dirty. Checks relating to fire safety were not routinely being carried out when the maintenance person was away from work. Environmental risk assessments had not identified the issues we found.

One floor of the service had been recently redecorated; however, it did not reach expected cleanliness standards. The management team took action to start remedying these issues during the assessment. Most people’s bedrooms were personalised, with their own artwork, furniture and belongings.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective training. Staff did not work together well to provide safe care that met people’s individual needs.

There were issues around the staff culture, where staff provided differing standards of care depending on the staff team on duty. Staff had not received key training in catheter care which meant people were at risk of receiving delayed healthcare support when something went wrong.

Recruitment records were not always complete and in line with expected standards. Staff and people commented that staffing could be short at times, making it difficult to spend meaningful time with people.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There were significant issues with cleanliness throughout the service. Bathroom grab rails and flooring was damaged meaning they could not be cleaned effectively. There was no clear process in place for ensuring deep cleans were carried out. Infection control audits had not identified the issues we found. Following the assessment the service has taken on support from the local infection control team.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored safely. People received their medicines on time. Where people had ‘when required’ medicines, protocols were in place to make sure people received them appropriately.