Fernery House

At the last inspection, the service was rated requires improvement and found to be in breach of 4 legal regulations. At this assessment we found that although the provider had made some improvements in areas identified by us and set down in their action plan, these had not consistently been sustained and embedded. The service remained in breach of regulations in relation to safe care and treatment, staffing, the way they gained people’s consent and assessed their mental capacity to consent and good governance. We identified an additional breach of legal regulation in relation to person centred care. The provider must send us an action plan detailing how they will address these breaches.

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgments about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The service did not consistently uphold these principles.

Care documentation was fragmented due to the transition to electronic records, and risk assessments were not always reviewed or updated, although work was in progress to complete these actions.

Safeguarding systems lacked robust oversight, and restrictive practices were not consistently reviewed in line with the Mental Capacity Act. Environmental safety required urgent attention, with some outstanding fire safety actions and poor maintenance in various areas of the home. Recruitment checks were incomplete, and gaps in records related to staff training and qualifications continued, including the Care Certificate, refresher courses in key areas such as dysphagia (swallowing difficulties) and mandatory autism training.

While medicines were generally managed safely, improvements were needed in areas of quality monitoring such as audits and staff competency updates. Infection prevention and control procedures required improvement, and staff did not consistently follow best practice.

Governance systems were ineffective, with audits failing to identify or address key areas. Leadership instability impacted continuity of care and progress on improvements.

Although some positive outcomes were achieved for people, these were not experienced consistently across the service. Opportunities for independence and meaningful engagement were limited for some people, and care plans and goals were not regularly reviewed.