Date of assessment: 15 July 2025 to 25 July 2025. Fernways provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service. At the time of this assessment, the service was providing personal care to 10 people. The site visit was carried out on 15 July 2025. This assessment was carried out by one inspector. We looked at 15 quality statements as part of this assessment. We gave the service 24 hours’ notice of the assessment. This was because we wanted to make sure someone would be available to support us with the assessment. We also spoke with people who used the service, their relatives, and staff to seek their views about the service. At the time of our assessment there was a registered manager in post. However, they had been absent from the service for longer than three months. The provider had made alternative arrangements to ensure the registered manager position was covered. An acting manager was in post, and they were being supported by the service manager and the registered managers from the provider’s other services. The last rating for this service was requires improvement (published 20 January 2023). This assessment was carried out to follow up on action we told the provider to take at the last inspection. The provider was previously in breach of the legal regulation in relation to the management of medicines and good governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations. The provider ensured medicines were managed safely. There was an effective system in place to monitor the quality of the service and identify shortfalls. This report only covers our findings in relation to the key questions Safe and Well-led which cover those breaches.
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Fernways, an extra care housing personal care service in Ilford, was rated Requires Improvement overall due to regulatory breaches in medicines management (Regulation 12) and governance (Regulation 17), including missed care calls, absent PRN protocols, MAR gaps without follow-up, and no handover records. Strengths included good person-centred care, effective multi-agency working, robust infection control, and positive feedback from people and relatives.
Concerns (8)
criticalMissed or late visits: “We found evidence of at least three missed calls concerning two people over the space of two days. We were concerned the provider would not have known the calls were missed as there was no system in place.”
criticalMedication management: “There were no protocols in place for PRN medicines...MAR audits highlighted numerous gaps where people's medicines may not have been given. When this had occurred, there was no record of follow up with 111, GP or medical practitioner.”
criticalGovernance: “There was no systematic means of picking up and following up on actions such as those recorded in the communication book...no system for recording interactions with medical professionals.”
moderateIncident learning: “It was not apparent whether incidents and accidents were being discussed regularly as there was no record of handovers and incident and or accidents were not a recurring item on team meeting agendas.”
moderateRecord keeping: “There was no record of handover. This meant there was no way of knowing what exactly staff handed over from one shift to another and there was a risk that important information could be missed.”
moderateStaffing levels: “Staff told us, '[Staffing levels are] low. It can be hit and miss; we struggle at certain times. We have a few members off sick, we do our best to step in and cover [with] overtime.'”
moderateLeadership: “The registered manager was unavailable for this inspection through long term absence from work...people and relatives were unclear who managed the service. We were provided with four different names.”
minorEnd-of-life care: “Care plans did not always contain information about people's end of life wishes. We discussed with the manager that there should be a consistent opportunity for this to be explored with people.”
Strengths
· Systems in place to safeguard people from abuse; staff understood reporting procedures and safeguarding training was up to date.
· Robust recruitment measures in place including DBS checks, employment history, references and proof of identification for all permanent and agency staff.
· Effective infection prevention measures including regular COVID-19 testing, ample PPE supplies, and enhanced cleaning regimes.
· Staff received induction, training and supervision; training covered medicines administration, moving and handling, and safeguarding.
· Service worked effectively with other agencies including GPs, district nurses, pharmacists and social workers to provide joined-up care.
Quality-Statement breakdown (25)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
This was a targeted COVID-19 IPC inspection of Fernways extra care service, which was inspected but not rated. Inspectors were assured on all eight IPC domains and found sufficient staffing with effective contingency planning.
Strengths
· Robust COVID-19 visitor controls including evidence of negative LFT and provision of PPE
· Regular staff testing with weekly PCR and daily LFT before shifts
· Sufficient staffing with contingency arrangements for COVID-19 shortages
· Up-to-date infection control policies, procedures and risk assessments aligned with government guidance
· All staff (including agency) trained in infection control and PPE use; correct PPE use observed
Quality-Statement breakdown (9)
safe: The provider ensured they had enough staff at all times to meet people's needs.Not rated
safe: We were assured that the provider was preventing visitors from catching and spreading infections.Not rated
safe: We were assured that the provider was meeting shielding and social distancing rules.Not rated
safe: We were assured that the provider was admitting people safely to the service.Not rated
safe: We were assured that the provider was using PPE effectively and safely.Not rated
safe: We were assured that the provider was accessing testing for people using the service and staff.Not rated
safe: We were assured that the provider was promoting safety through the layout and hygiene practices of the premises.Not rated
safe: We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.Not rated
safe: We were assured that the provider's infection prevention and control policy was up to date.Not rated