CQC report explained · a residential care home
What the CQC found at Ladydale Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by risk assessments, suitable recruitment checks and safeguarding procedures. Medicines, infection control, equipment and emergency evacuation plans were generally managed safely, although staffing feedback was mixed.
- Effective?
- Good
- The home followed the principles of the Mental Capacity Act, offered choices and checked consent. People received suitable food and drink, health professional support and care from trained staff.
- Caring?
- Good
- Inspectors saw staff treating people with kindness, patience and respect. People were supported to make choices, keep their dignity and do as much as possible for themselves.
- Responsive?
- Good
- Care plans contained personal information and staff knew people's needs and preferences. Activities, communication needs and end of life wishes were considered, and complaints were generally responded to.
- Well-led?
- Good
- Audits and other checks were being used to identify and fix problems. People, relatives and staff said the acting manager was approachable, but there was no registered manager in post.
What inspectors found, July 2018
Ladydale Care Home is rated Good; inspectors found safe, kind and personalised care, with improvements sustained after earlier inspections.
Inspectors visited without notice on 31 May 2018. They spoke with people living in the home, relatives, staff and health professionals. They observed care and reviewed care plans, medicine records, staff files and quality checks.
All five areas were rated Good. Inspectors found enough staff overall, safe medicines management, suitable training, kind care and personalised support. People were offered choices, supported to stay independent and helped to access health professionals.
The inspection followed five earlier inspections where improvements were needed in care quality, records and management checks. Inspectors found these improvements had been made and sustained. There was no registered manager at the time, and the deputy was acting as manager.
Improvements sustained
The inspection found that earlier problems with care quality and management checks had been addressed and kept improved.
“We found improvements had been made and sustained.” from the report
Safe care
Risk assessments were in place and staff followed them. The home also learned from accidents and incidents to reduce the chance of them happening again.
“Risks to people were assessed and planned for to help keep people safe.” from the report
Kind and respectful staff
People were treated with kindness and patience. Staff supported dignity, independence and personal choices.
“People and relatives told us staff were kind, caring and treated people with respect.” from the report
Personalised support
Care plans included detailed information about how people preferred to receive personal care, get dressed and communicate.
“Staff knew people well and people's plans contained good personal detail to help staff support people in an individualised way.” from the report
Quality monitoring
The home used audits to check care, medicines, weights, cleanliness, complaints and accidents. Action was taken when checks identified problems.
“We saw audit systems were in place which had been effective at identifying and rectifying concerns.” from the report
No registered manager
needs fixingThere was no registered manager in post. The deputy was acting as manager while recruitment continued.
“The home did not have a registered manager in post.” from the report
Mixed views about staffing
needs fixingAlthough inspectors judged there were enough staff overall, one person and a relative said staff could be slow to respond or that staffing was insufficient. Staffing was due to increase.
“There was mixed feedback about staffing however overall there was a sufficient amount of staff available to support people.” from the report
One complaint still open
minorOne relative told inspectors that a complaint had not yet been resolved. The acting manager was still responding to it during the visit.
“One relative made us aware of a complaint they had made which had not yet been resolved.” from the report
Topical medicines records
needs fixingThe new electronic record did not initially include the full details needed for topical creams and lotions. Paper records were reintroduced the same day while the software was being improved.
“Although this allowed accurate, real time documentation but it did not include protocols or name the actual cream or lotion.” from the report
- 01Who is currently managing the home, and what is the progress on appointing and registering a permanent manager?
- 02How do you use the dependency tool to decide staffing levels, and how do you respond if people experience delays?
- 03How are topical creams and lotions recorded now, and has the electronic system been updated with the required details?
- 04How are complaints tracked, and can relatives see when an issue has been fully resolved?
- 05What further improvements are planned for the garden areas and the electronic care records?
This was an unannounced inspection covering all five CQC questions, including the care provided and the care home's premises, and checking improvements identified at earlier inspections. This explanation was written from the published report of 18 July 2018 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, July 2017
Overall rating Requires Improvement; inspectors found safe care, but legal safeguards and management records were not yet consistently reliable.
This was an unannounced focused inspection on 10 May 2017. Inspectors checked whether the home had acted on four breaches found at the previous comprehensive inspection. They spoke with people, relatives, staff and others, observed care, and checked care, medicine, recruitment and management records.
The home had improved and was no longer breaching those four regulations. Safe was rated Good. Inspectors found enough suitably checked staff, safe medicine records, plans for risks such as falls and skin damage, and appropriate safeguarding referrals.
Effective and well-led were both rated Requires Improvement. Mental capacity assessments and evidence of Lasting Power of Attorney were not always complete. One person's DoLS condition was not consistently followed. Audits had found some problems, but action had not always been completed and some care plans needed updating.
Safe staffing
Inspectors found enough staff to support people safely. Recruitment checks were also completed before staff started work.
“There were sufficient numbers of appropriately recruited staff to support people.” from the report
Food and health support
People had choices of food and drinks suited to their needs. The home involved health professionals when required and monitored people's weight.
“People were supported to maintain their nutritional intake and people told us they were happy with the food” from the report
Listening to feedback
The manager sought views through meetings and surveys and recorded actions taken in response. Inspectors saw examples including garden improvements and changes to bedroom door signs.
“The registered manager had responded to the feedback with a 'You Said, We Did' document” from the report
Mental capacity and DoLS
seriousSome mental capacity assessments and Lasting Power of Attorney evidence were missing. One person was not consistently offered the opportunity required by their DoLS condition and was sometimes restricted.
“This meant the home were not consistently complying with a DoLS condition and the person was sometimes being restricted.” from the report
Incomplete management follow-up
needs fixingAudits identified problems, but action had not always been completed. Some care plans did not clearly set out the support staff needed, including plans for skin care and diabetes.
“Action had not always been taken to remedy issues that had been found.” from the report
Medicine guidance and training
needs fixingSome people did not have clear guidance for staff about when to give PRN medicines. Staff applying topical medicines did not all have formal medicine training.
“We found some people did not have guidance in place for staff when the medicine was” from the report
- 01How do you now make sure every person has a current mental capacity assessment where needed?
- 02How do you check that every DoLS condition is followed and recorded, including opportunities to leave the home?
- 03Can you show how Lasting Power of Attorney evidence is checked and kept in people's files?
- 04What action has been completed from the audits about skin care, diabetes care plans and other records?
- 05Do all staff who apply topical medicines have the required training, and are PRN protocols in place for every appropriate medicine?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed in this report. This explanation was written from the published report of 8 July 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 Ladydale Care Home
7 rated inspections over 3 years: the service has held its Good rating throughout.
- July 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- April 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- September 2016Inadequatestayed InadequateSafe: InadequateEffective: InadequateWell-led: Inadequate
- July 2016Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 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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