The overall rating for Fern Court in Gloucester has dropped from good to inadequate, following an inspection by the Care Quality Commission (CQC) in February. CQC has now issued the provider with two warning notices which require it to improve the standard of care.
Fern Court is a residential care home providing personal care for up to 13 people with a learning disability, mental health condition, or autistic people.
CQC carried out an unannounced focused inspection to look at how safe and well-led the service was, after receiving information of concern about staffing and risks to people’s safety. The rating for safe and well-led also dropped from good to inadequate. Caring, effective and responsive were not inspected. The service is now in special measures, which means it will be closely monitored and re-inspected within six months to check that improvements have been made.
Rebecca Bauers, CQC’s head of adult social care inspection, said:
“When we inspected Fern Court, we were concerned the service wasn’t putting people’s care needs first, and sometimes staff didn’t support people in a positive way that promoted their privacy and dignity. Because of this, we felt the service was at risk of developing a closed culture, which is when institutionalised practices are used, increasing people’s dependence on the manager and staff.
“We found some people’s care plans were out of date, or contained contradictory information, and some care plans said that people sometimes showed signs of distress which could be challenging, yet there was no guidance provided to help staff manage this safely with minimal physical intervention. This meant that people were at risk of abuse.
“It was also concerning that the provider had carried out a review of incidents in the home, yet they hadn’t learnt from this and made improvements to prevent them from happening again.
“Following the inspection, we told the provider to make a number of improvements to ensure people receive safe care and issued a warning notice to ensure that the improvements were made. I am pleased to report the provider is now working closely with the local authority and other partners to address the failings. The local authority produced an action plan for improvements, and the provider was developing their own plan to help prioritise the improvements, as well as increasing the presence of management in the home and focusing on improving staff skills. We will continue to monitor the service to ensure that the improvements are fully embedded.”
CQC found the following during this inspection:
- People were not always protected against avoidable harm. Incidents and accidents were not investigated in a robust way and learning from events was not used to prevent recurrence of the same issue
- People's care plans, risk assessments and positive behaviour support plans were out of date and contained inaccurate or conflicting information
- Infection prevention and control was unsatisfactory. This placed people, visitors, and staff at risk of infections
- The provider had not taken steps to ensure that people would be protected from risks associated with fire safety and legionella
- People did not always receive their medicine as prescribed and staff did not always clearly document when people received ‘as required’ medicine, increasing the risk of errors
- Monitoring systems were not always effective as the records supporting the management of the service were not always reliable
- The service had not always sent required notifications to the Care Quality Commission (CQC) without delay. The service was not able to demonstrate that it was meeting some of the underpinning principles of right support, right care, right culture. Care was not always person-centred, and inspectors saw people’s privacy and dignity were not always promoted.
Full details of the inspection are given in the report published on our website.
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