Feltwell Lodge

Updated 14 January 2023

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 site visit was carried out by 2 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

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

Notice of inspection

This inspection was unannounced. Inspection activity started on 14 November 2022 and ended on 25 November 2022. We visited the home on 14 November 2022.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and healthcare professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who lived at the service, however, not all people were able to tell us about their experience of living in the home, so observations of care and support were also made. We spoke with 6 relatives, received written feedback from a further 8 relatives and spoke with 7 staff members. These included the registered manager, the deputy manager, the head of care and care staff.

We received written feedback from a further 11 staff members. A selection of records was also viewed, and these included the care plans and associated records for 5 people who used the service. The medicines records for 8 people were also assessed. The governance records viewed included policies and procedures, staff recruitment records, training information, quality monitoring audits and maintenance records.

Updated 14 January 2023

About the service

Feltwell Lodge is a residential care home providing personal care and accommodation to up to 45 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 33 people using the service. The home is an adapted period building with accommodation over two floors.

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

Some areas of the service required improved oversight of safety and quality monitoring. An uncovered and hot radiator in one person’s bedroom presented a burn risk. Monitoring of people’s fluid intake wasn’t always completed to reduce the risk of dehydration.

The provider did not follow the latest COVID-19 government guidance and required people’s relatives to make an appointment to visit them. We have made a recommendation that the provider work in accordance with the guidance and remove restrictions on visiting.

People were practically supported, by care staff to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. However, records did not evidence this approach as required by the Mental Capacity Act 2005 (MCA). We have therefore made a recommendation regarding adherence to the MCA. Some relatives told us they were not always involved in their family members care planning.

Most medicines practices were safe, and people received their prescribed medicines in the way they preferred, however improvements were needed to the record keeping of topical medicines.

Feedback from relatives and people was positive about the care and support people received, and the friendliness of the staff team. However, end of life care plans were not completed where people were receiving care at the end of their lives or to prepare for this. We have made a recommendation to the provider to review their care planning process. Staff were positive about how the service was managed and the culture and morale of the team.

There were sufficient safely recruited staff on duty to keep people safe. People were kept safe from the risk of abuse and staff understood their safeguarding responsibilities and any action they needed to take.

The registered manager was transparent and committed to learning lessons when things went wrong. Throughout the inspection, the registered manager displayed a transparent approach. They spoke openly about challenges caused by the COVID-19 pandemic and shared the plans they had in place to address them.

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

Rating at last inspection

Following a change to the providers legal entity, this service was re-registered with us in November 2020 and this is the first inspection since that date.

Why we inspected

We inspected this service due to it being a newly registered 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.

Enforcement and Recommendations

We have identified a breach in relation to good governance at this inspection. We also made three recommendations that the provider work to best practice in end of life care, ensuring they work to The Mental Capacity Act and in ensuring people do not have any restrictions applied to their visitors.

We will continue to monitor the service and will take further action if needed. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.