CQC report explained · a residential care home
What the CQC found at Felbrigg House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm through risk assessments, safety checks, safeguarding processes and suitable staffing. Inspectors also found that medicines and infection control were managed safely.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Managers were visible, approachable and understood people's needs. Governance systems, staff meetings and feedback from people and relatives supported the management of quality.
What inspectors found, March 2023
Felbrigg House is rated Good; inspectors found safe, kind and personalised care, with strong management and staffing.
This was an unannounced inspection on 15 February 2023. One inspector observed care, spoke with people and staff, reviewed care plans, medicine records and management records, and contacted relatives and visiting professionals afterwards.
The inspection found that people were supported safely and had choice and control over their lives. Staff understood people's communication needs, health risks and medicines. There were enough staff, and infection control arrangements were considered effective.
The home was also judged well-led. Managers were visible and approachable, staff knew people well, and audits were used to identify and address shortfalls. The overall rating was Good. Safe and Well-led remained Good, while the other areas were not inspected during this visit and their previous ratings were used for the overall rating.
Choice and independence
People were supported to make choices, take positive risks and do as much as possible for themselves. Staff used the least restrictive approach and supported people to maintain their health and wellbeing.
“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” from the report
Kind and respectful care
Inspectors found that staff understood people's individual needs and protected their privacy and dignity. Care was described as compassionate and tailored to each person.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Staffing and activities
There were enough staff to provide one-to-one support, activities and visits. Staffing levels changed to reflect people's appointments, activities and individual needs.
“There were enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted.” from the report
Strong management checks
The management team carried out regular audits and acted when they found shortfalls. Staff understood their roles and managers worked with people, relatives and other professionals.
“Governance processes had been effective in identifying shortfalls and action was taken when any shortfalls were identified.” from the report
Safe medicines support
Staff supported people to take medicines safely and encouraged independence where appropriate. Inspectors found guidance for medicines taken when needed and evidence that medicines had been reduced for some people.
“Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both).” from the report
Inspectors raised no specific concerns in this report.
- 01How are staffing levels adjusted when people need one-to-one support, attend appointments or take part in activities?
- 02How do you review medicines that people take independently or only when needed?
- 03How often are epilepsy, diabetes and other individual health risks reviewed, and how are staff updated?
- 04What were the findings of the most recent audits, and what actions are still open?
- 05How do you currently assess the quality of care in Effective, Caring and Responsive, which were not inspected during this visit?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 16 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2017
Rated Good; inspectors found safe, kind and person-centred care, with some records needing improvement.
Inspectors made an unannounced comprehensive visit on 31 July 2017. They spoke with four people, three relatives, the registered manager and two staff members. They also reviewed care plans, risk assessments, medicines records, staff files, rotas and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people felt safe, staff knew them well, and people were supported to make choices and become more independent.
There were some areas for improvement. Care plans contained duplicated information and were difficult to use. Some handwritten medicine entries were not checked and signed by two staff. The provider had not asked other stakeholders for feedback.
People felt safe
People appeared relaxed and were able to tell staff when they needed help. Staff knew how to recognise abuse and respond to concerns.
“People indicated that they felt safe. They were happy, smiling and relaxed with the staff.” from the report
Personalised support
Staff knew people's routines, communication methods and preferences. Support was adjusted to help people make choices and become more independent.
“People received care that was personal to them.” from the report
Activities and independence
People were supported to try new experiences and take part in activities inside and outside the home. Inspectors saw evidence that this helped some people gain confidence.
“People were encouraged and supported to go shopping, do their laundry and generally lead a fulfilling life which promoted their independence and skills.” from the report
Kind relationships
Staff treated people with warmth, patience and respect. Relatives described a calm atmosphere and strong trust in staff.
“The staff interacted with people with warmth and compassion.” from the report
Good oversight
The registered manager and provider carried out regular checks on care plans, medicines, health and safety and other areas. Staff, people and relatives had opportunities to give feedback.
“The provider had a quality assurance system to monitor the quality and safety of the service and to identify any areas for improvement.” from the report
Care plans were hard to use
needs fixingCare and health plans contained duplicated information and were cumbersome. The registered manager had identified this and planned to streamline them.
“The care and health plans contained a lot of duplicate information and were cumbersome.” from the report
Medicine entries needed a second check
needs fixingSome medicines were written by hand onto medicine records. These entries were not signed by two staff members to confirm they were correct.
“When staff had entered these medicines on the MAR they were not signed by two staff members to check the entry was correct.” from the report
Feedback was not broad enough
minorThe provider asked people, relatives and staff for feedback, but had not asked other stakeholders. The provider said this would be addressed.
“The provider had not requested feedback from other stakeholders.” from the report
- 01What changes have been made to reduce duplicated information and make care plans easier for staff to use?
- 02How are handwritten medicine entries checked and signed now?
- 03How do you make sure there are enough trained staff to support people's activities and individual routines?
- 04How are people involved in reviewing their care and making decisions about their daily lives?
- 05Have you started asking other stakeholders for feedback, and what changes have resulted?
This was an unannounced comprehensive inspection covering all five CQC questions and the overall rating. This explanation was written from the published report of 24 August 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Felbrigg House
4 rated inspections over 8 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodWell-led: Good
- January 2017Goodstayed GoodResponsive: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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