Felbury House

Updated 20 October 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by three inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Felbury House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Felbury House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We looked at all the information we held about the provider including information they sent us when they registered with us. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 10 people who used the service and two family members about their experience of the care provided. We also spoke with 10 members of staff, including the registered manager, deputy manager and care staff. The nominated individual joined for the latter part of the inspection feedback. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed four people’s care plans, three pre-admission assessments and 10 medicine records. We also reviewed five staff records in relation to registration, recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 20 October 2022

About the service

Felbury House is a residential care home registered to provide personal care to up to 30 people. People living at the service have a range of needs including physical disabilities and needs associated with older age and frailty. At the time of our inspection there were 29 people using the service.

People’s experience of using this service and what we found

There was a lack of robust provider oversight and governance of the service. Aspects of leadership and governance were not effective in identifying some of the concerns found on inspection related to medicines management and recruitment systems. Measures put in place by the provider to address what some staff perceived to be a culture of unfairness and favouritism within the home, were ineffective.

We received mixed feedback about activities. Whilst people who were able to participate in activities out of the home spoke positively about this, those who were less able or who chose not to go out, told us there was little provision for them. We have made a recommendation about how activities are provided.

People received safe care and support. The provider had systems and processes in place to safeguard people. Staff were trained and knew how to report any concerns they may have. People were happy with the care they received and felt safe with the staff that were supporting them. They told us there were enough staff to ensure their needs were met in a timely way. Staff undertook training to ensure they were suitably skilled and knowledgeable for the role.

Assessments were completed in response to any risks identified to people's health, safety and wellbeing. Guidance was in place for staff, so they knew the actions they needed to take to reduce potential harm. Any incident, accident or untoward event that occurred at the service was investigated by the registered manager.

People spoke of the kindness of staff and told us they were treated with respect and dignity. We observed how staff interacted with people in a very kind and caring manner. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People had access to healthcare services and staff supported them to attend appointments. Where needed, staff engaged with healthcare professionals to promote good outcomes for people.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 14 June 2021 and this is the first inspection. The last rating for the service at the previous premises was good, published on 14 December 2018.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.