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Inspection Summary

Overall summary & rating


Updated 25 October 2017

This unannounced inspection of Mary Feilding Guild took place on the 21 August 2017.

The inspection was a focused inspection and was prompted in part by notification of an incident following which a service user died. The information shared with CQC about the incident indicated potential concerns about the management of risks in relation to the safety of the premises. This inspection examined those risks.

This report only covers our findings in relation to two outcomes, safe and well-led. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Mary Feilding Guild on our website at At the last inspection the service was rated 'Good' overall.

Mary Feilding Guild is a not for profit charitable organisation registered to provide accommodation and personal care for up to 43 older people. The aim of the service is to provide support to older people who are independent both physically and mentally. At the time of the inspection there were 39 people using the service.

The provider had recently recruited a new manager who had applied to be registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

In response to the serious incident that had occurred in July 2017, the provider had commissioned an external contractor to carry out a risk assessment of people’s rooms and communal areas. This assessment had highlighted a number of risks to people’s safety. The provider was taking action to make sure these risks were mitigated.

Individual risks had been identified for people using the service in connection with their care provision. There was detailed information for staff about how to mitigate these risks, for example, to make sure people had their mobility aids with them at all times.

The systems used to identify and assess potential risk to people’s safety were not always clear which meant there might be risks that were not picked up by staff.

Systems to assess, monitor and improve the safety and maintenance of the building were not always effective and there was no management oversight of this process.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was in relation to good governance. You can see what action we told the provider to take at the back of the full version of the report.

Inspection areas


Requires improvement

Updated 25 October 2017

The service was not always safe.

Systems for assessing the risks people faced in relation to their care were not always clear and did not assess the severity of the risk so appropriate control measures could be put in place.

As a result, of the above we have changed the rating for this key question from ‘Good’ to ‘Requires Improvement’.



Updated 27 May 2016

The service was effective. People living at the service and their relatives told us they had confidence in staff skills and knowledge, and we could see staff were trained in key areas.

People were supported to maintain good health and there was a wide range of food available to support good nutrition.

Staff were aware of issues of consent and Deprivation of Liberty Safeguards (DoLS) were in place where necessary.



Updated 27 May 2016

The service was caring. People living at the service told us staff were kind, caring and patient. Importance was placed on dignity and respect for people living there.

People were actively encouraged to remain independent and there were multiple kitchen and laundry facilities to enable this.

The gardens and the building were beautifully maintained which benefitted the people living there.


Requires improvement

Updated 27 May 2016

The service was not always responsive. Care records were not easy to navigate. This made it difficult to understand a person’s care needs.

The service had not responded robustly to the management of falls, although there were new procedures now in place to support staff to keep people safe.

The activities at the service were varied, creative and met the needs of the majority of the people living at the service.


Requires improvement

Updated 25 October 2017

The service was not always well-led.

The systems for assessing, monitoring and auditing the safety of the premises were inconsistent.

As a result, of the above we have changed the rating for this key question from ‘Good’ to ‘Requires improvement’.