Fern House was rated Inadequate overall following a focused inspection of Safe and Well-led domains, with continued breaches of Regulations 12, 13, 17 and 18 including unsafe medicines management, failures in safeguarding reporting, ineffective governance, and a significant undercount of accidents and incidents. The service was placed in special measures due to widespread and significant leadership shortfalls that had not improved since the previous requires improvement rating.
Concerns (8)
criticalMedication management: “Topical medicine administration records (TMARs) were not always in place for prescribed creams to ensure staff knew how, where and when to apply them.”
criticalSafeguarding: “The provider did not always report safeguarding incidents to the local safeguarding authority and CQC. For example, incidents between people who used the service.”
criticalIncident learning: “People were having multiple falls yet there was no evidence of learning or action taken to prevent repeat events.”
criticalGovernance: “The analysis for December 2020 showed a total of 5 incidents in the service yet our review found 23 incidents. This included multiple falls and incidents between people using the service.”
criticalLeadership: “There was a lack of effective management and leadership. Staff described managers as friendly and approachable however, they said issues raised were not always acted upon.”
moderateRecord keeping: “Care records for people using the service were not always accurate or up to date. Risk assessments and care plans were not always accurate or updated when needs changed.”
moderateStaffing levels: “The provider had no formal system in place to calculate safe staffing levels. Duty rotas showed these levels were not maintained.”
moderateCare planning: “One person had fallen frequently which resulted in serious injury on two occasions but their assessment showed they were at low risk of falls.”
Strengths
· Staff recruitment processes were safe with all required checks completed before new staff started employment.
· Robust infection control procedures were in place which helped keep people and staff safe during the COVID-19 pandemic.
· People and relatives gave consistently positive feedback, with staff described as 'marvellous', 'very kind' and 'absolutely first class'.
· Staff supported people to keep in touch with family through video and phone calls during visiting suspension.
· People lived in a clean and pleasant environment.