CQC report explained · a nursing home
What the CQC found at Ladybrook Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe, and systems were in place to manage abuse, accidents, risks, medicines and infection control. Inspectors found some gaps in care records and said some medicine recording systems could be further developed.
- Effective?
- Good
- People's needs were assessed and care plans were personalised. Staff received training, people were supported with food and healthcare, and the service was working within the principles of the Mental Capacity Act.
- Caring?
- Good
- People and relatives generally spoke positively about staff. Inspectors saw staff treating people with patience, respect and compassion, including when people living with dementia became distressed.
- Responsive?
- Good
- Care plans were person-centred, activities were available and complaints were acted on. However, communication plans did not always give newer staff enough guidance about how to communicate with people.
- Well-led?
- Good
- Inspectors found open and responsive management, regular meetings and systems to monitor training, risks and improvements. The service had a culture of learning and staff felt able to raise concerns.
What inspectors found, July 2023
Ladybrook Manor is Rated Good; inspectors found kind, safe care, but some care and communication records needed improvement.
Inspectors visited on 18 and 20 April 2023 without announcing the visits. They spoke with people, relatives and staff, observed care, and checked care records, recruitment files and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives generally said people were safe, supported and treated kindly.
Inspectors found some gaps and inconsistencies in records showing the care people had received. They also found that communication plans did not always explain how best to communicate with people. The registered manager had already started an action plan and responded promptly to the feedback.
This was the first inspection of the newly registered service. The previous provider had been rated Good in 2018.
Kind and respectful care
People and relatives generally described staff as caring, friendly and approachable. Inspectors observed patience, respect and compassion, including when people became distressed.
“During the inspection Inspectors observed occasions in the 'reminiscence' neighbourhood where people became distressed unsure of their surroundings.” from the report
People felt safe
People and relatives generally felt safe. Risk assessments, safeguarding systems, equipment checks and incident reviews were in place.
“People told us they felt safe. A person said, "If I had worries, I know it would not be taken lightly and would be dealt with positively.” from the report
Personalised support
Care plans included people's histories, preferences and support needs. People could choose activities and were supported to access healthcare.
“Care plans were personalised with key information on how best to support.” from the report
Responsive management
The registered manager acted promptly when inspectors raised issues. People, relatives and staff had opportunities to give feedback through meetings and other channels.
“The registered manager was passionate regarding their role, proactive to any queries we raised and acted upon theses in a prompt manner.” from the report
Care records were not always complete
needs fixingInspectors found gaps and inconsistencies in records showing the care people had received. The manager said this was already being addressed through an action plan.
“We identified some gaps in the records completed by staff which meant there were some inconsistencies in how the delivery of people's care was recorded.” from the report
Communication plans needed review
needs fixingSome care plans did not explain how best to communicate with a person. This could leave newer staff without enough guidance.
“The Accessible Information Standard was not being fully met.” from the report
Earlier staffing inconsistency
minorSome people reported inconsistency in staffing, although they recognised that regular staffing had improved in recent months.
“People told us there had been some inconsistency over staffing, however acknowledged an improvement of regular staffing in recent months.” from the report
- 01What changes have been made to ensure every person's care is recorded consistently?
- 02How have communication plans been reviewed so that newer staff know how to communicate with each person?
- 03How are records for thickening agents checked and kept up to date?
- 04What has been done to maintain the improvement in regular staffing?
- 05How are people and relatives told about progress with the action plan?
This was an unannounced inspection covering all five CQC questions and included infection prevention and control checks. This explanation was written from the published report of 8 July 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, February 2022
Inspected but not rated; inspectors were assured that infection control, visiting arrangements and COVID-19 safety measures were in place.
This was an announced, targeted inspection on 19 January 2022. It focused on infection prevention and control, visiting arrangements, and whether COVID-19 staffing pressures affected care.
Inspectors found the home clean, tidy and free from odours. Staff used personal protective equipment correctly. The home had extra staff and one-to-one activities in the reminiscence neighbourhood during isolation.
Inspectors were assured about testing, admissions, visiting, social distancing, shielding, hygiene and the management of outbreaks. The service was inspected but not rated, so this report does not give an overall quality rating.
Clean environment
Inspectors found all areas visibly clean, tidy and free from odours.
“All areas of the home were visibly clean, tidy and odour free.” from the report
Infection control
Staff used PPE correctly, and the home had additional precautions in the neighbourhood for people living with dementia during isolation.
“We saw staff used appropriate personal protective equipment correctly.” from the report
Learning from the outbreak
The manager investigated the reasons for the COVID-19 outbreak and took action. A quality manager also visited weekly to provide support.
“Following an outbreak of COVID-19 the manager conducted a root cause analysis investigation to find the reasons for the outbreak and take appropriate action.” from the report
Inspectors raised no specific concerns in this report.
- 01What measures are currently in place to manage COVID-19-related staffing pressures?
- 02What did the investigation into the previous COVID-19 outbreak find, and what actions were taken afterwards?
- 03How are visits facilitated if there is an infection outbreak or someone is isolating?
- 04How does the reminiscence neighbourhood support people living with dementia who may leave their rooms during isolation?
- 05How often are quality control visits now carried out, and what do they check?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 8 February 2022 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 Ladybrook Manor
2 rated inspections over a year: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2023GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- December 2021
Registered with the Care Quality Commission on 10 December 2021.
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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At least 100 live-in carers within about an hour of Stockport
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 88 can care for a couple. 10 years' experience on average.
“Primrose is a very kind and compassionate healthcare professional”
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
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