Lady Jane Court Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People’s needs were assessed and reviewed effectively to ensure they were in receipt of the most up to date treatment, care, and support. There were up to date policies and procedures in place, based upon current legislation and best practice guidance, to ensure people's care and treatment was based on their individual needs. Staff worked collaboratively with external health and social care professionals who provided support guidance to achieve quality outcomes for people. This enabled people to maximise independence, choice and control. Staff engaged with people, were respectful and obtained consent before delivering care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People confirmed how they were involved in the assessment, development and review of their care and treatment needs. A person said, “I’m aware of my care plans and I am involved in discussions and decisions about my care.” A relative said, “We were fully involved in the assessment and communication is good. We were invited to attend a 6 month review meeting along with relation.”

Staff were positive about the guidance and support provided in how to meet people’s individual needs. Staff advised guidance was sufficiently detailed and regularly reviewed to ensure it reflected people’s current needs. Staff demonstrated a good understanding of people’s care needs, including the importance of people’s communication, emotional and well-being needs. Staff were aware of the importance of consistency and continuity in care. The registered manager advised how care plans were reviewed and amended to reflect any changes. In addition, changes to people’s needs were discussed during the daily staff handover and heads of department meetings.

The provider had a pre-assessment process. This included a face to face pre- assessment meeting with the person and family or loved ones before people transferred to the service. Pre-assessments records reviewed were found to be well completed, detailed and included all aspects of physical, emotional and well-being care and support needs. This included routines and preferences and personal history to support staff. New admissions were discussed with staff during the daily 10/10 meetings and daily handover meetings. Care plans and risk assessments were developed with the involvement of the person and or their relatives. There was a process of care plans and risk assessments being reviewed monthly and amended if required or sooner if changes occurred. Changes were clearly recorded to support staff awareness and understanding. Care plans overall were found to reflect people’s individual needs, routines and preferences. This included people’s communication needs. Information could be provided in easy read, large print, audio or braille if required. The registered manager had an open door policy and met with relatives at any time they requested to discuss their loved ones care and treatment. The registered manager had identified a 4 week post admission review would be helpful and was in the process of implementing this. The provider used recognised assessment tools to assess and monitor people’s care needs, such as Malnutrition Universal Screening Tool (MUST), moving and handling and oral health. The provider was in the process of introducing a new clinical pain assessment tool.

People confirmed the care and treatment they received was based in their individual needs. People spoke positively about the quality and choices of the menu. A person said, “It's better cooking than what I could do. The food is really good, we've not had a bad meal since we've been here.” A relative said, “Drinks are always on offer, the water in her jug is always fresh and changed often, there is fruit juice, tea and coffee. They cater for individual choices / preferences with meals.” One relative raised a concern about meeting people’s individual preferences of meal choices and we raised this with the registered manager who agreed to follow it up.

Staff told us how changes to policies, procedures and guidance were communicated with them. This included completing refresher training to ensure their practice was based on current best practice guidance and legislation. Staff told us how they monitored people’s food and fluid to ensure risks associated with malnutrition and hydration were manged and mitigated. The registered manager confirmed policies and procedures were up to date. They said staff were required to read and sign to confirm they had read and understood policies and procedures. The registered manager confirmed the monitoring arrangement of people’s food, fluid and weights, and the actions taken if concerns were identified.

The provider had up to date policies, based upon current legislation and best practice guidance. Recognised assessment tools were used to assess and monitor people’s needs. Policies and procedures were discussed in staff meetings and supervisions. The provider and registered manager kept up to date with best practice via external and internal meetings and forums, this information was shared with staff. Processes were in place to assess and monitor nutrition and hydration needs for individuals. People's dietary needs and preferences were shared with kitchen staff in addition to detailed associated care plans and risk assessments for care staff to follow. People’s food and fluid input was recorded where required and monitored. Clinical needs were regularly reviewed and discussed during monthly clinical needs meeting and via a weekly GP ward round held at the service.

People were positive about how staff worked with healthcare professionals to ensure their health conditions and care and treatment needs were consistently met. One person told us, “I saw the GP yesterday who visited the service, the chiropodist visits 6 weekly, our health needs are well met.” A relative said, “Communications are always good, I take [relation] to the dentist, but there is very good communication with the hospital, GP etc.”

Staff confirmed the processes and procedures in place to share information with others such as the ambulance service and hospital staff to ensure people received consistent care. A staff member said, “We share information with others such as ambulance and hospital staff. We also follow recommendations made by others such as the GP, speech and language team and physiotherapists.” The registered manager advised of the procedure of people transferring to other care facilities and what documentation was shared to ensure people’s needs were known and understood.

Feedback from external healthcare professionals working with the service and commissioners, was positive regarding how well staff from the service worked with them. A professional said, “ The staff are aware of when I'm visiting and provide me with the information I need and support me whilst visiting the patient if needed. Any recommendations made staff follow, I have no concerns.”

Staff worked collaboratively with external health and social care professionals such as social workers, GP's, physiotherapists, occupational therapists, speech and language team, and community nursing team. All need admissions were reviewed by the local GP. Any treatment plan that has been prescribed by a visiting health professional was incorporated into the individual person's care plan. Copies were also scanned into the provider's electronic care records platform so all care staff are able access any additional information that has been supplied by external agencies or professionals.

People told us how well staff supported them with their health and well-being needs. A person said, “My health needs are well met and understood by staff, I’m happy with the care and support I receive.” Overall relatives were confident their relations health care needs were well met.

Staff confirmed they had sufficient guidance about people’s health conditions and guidance of how to meet these and had received training to enhance their understanding. Staff confirmed how people were supported to attend health appointments and access heath services and screening. Staff also demonstrated a good awareness of the importance of physical activity and the impact this can have on people’s well-being. The registered manager confirmed how people’s health and well-being was monitored and how any changes or concerns were shared during staff hand overs and during the daily heads of department meetings. The registered manager also told us how they had oversight to ensure health needs were followed up as required with health professionals.

The provider had systems and processes that assessed and monitored people’s health care and treatment needs. Records demonstrated partnership working with health care professionals and any recommendations being implemented. The provider was able to demonstrate how people were supported to attend health appointments and health screening. People were also encouraged to take part in activities to help their physical wellbeing.

People confirmed they were well supported with their health, care and well-being needs. A relative said, “We couldn’t ask for anything more, in a home, we honestly couldn’t, and we are very grateful [relation] is so well cared for.”

Staff confirmed the process of how people’s health care needs were monitored and gave examples of action taken when concerns were identified. The registered manager said, “ We have a monthly clinical risk meeting and a weekly visit by the GP, any clinical needs or concerns are quickly identified and followed up.”

The provider had systems and processes that continually assessed and monitored people’s individual health and well-being needs. This included monthly care plan and risk assessment reviews. These reviews would be completed sooner if changes occurred. A weekly GP visit supported people and staff in reviewing healthcare needs quickly. The provider had robust communication systems to enable staff to effectively exchange information quickly and easily. This ensured people’s needs and outcomes were acted upon and monitored. The provider used evidence based clinical guidance to support people to achieve positive outcomes. The use of assistive technology supported people identified at being at risk of falls. The provider was in the process of implementing a new pain assessment tool used for people who may find it difficult to express pain.

People told us consent was sought before care was provided. One person said, “Staff are polite and respectful, they knock on the door and wait for a response before they enter.” A relative said, “[Relative’s] wishes are taken into account as far as possible, they [staff] are good at listening and adapting.” Another relative said, “They [staff] are very receptive of my relation’s needs, it seems as if they really love them. They take their needs and wishes seriously.”

Staff showed a basic understanding of the mental capacity act (MCA) principles. They understood the importance of seeking consent before care and treatment was provided. The registered manager told us how they completed daily walkarounds and this included observations of staff engagement with people to ensure care was person centred, respectful and consent was sought before care was delivered.

Where people had capacity to consent to their care and treatment and the service they received, the person had confirmed their agreement by signing specific care plans and other relevant documentation. Where people lacked capacity to consent to their care and treatment, capacity assessments and best interest decisions had been completed. Records of MCA assessments and best interest decisions that we reviewed were not always consistently detailed and at times the assessment and decision making process lacked detail. Initial MCA assessments also recorded some people had fluctuating capacity, however there was no further information as to what this meant for the person and actions of staff required. We discussed our findings with the registered manager who agreed to follow this up.