Lady Jane Court Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were protected from the risk of harm and abuse. People's risks were well managed and mitigation was in place to prevent such risks from occurring. Staff knew people's needs well, enabling them to provide effective support. The environment was clean and free from potential hazards. There were good infection control processes in place. There were enough well trained staff to effectively and safely meet people’s needs. Staff were recruited safely. During our assessment of this key question, we identified some medicines due to be returned were not always stored in the most effective way. This was brought to the attention of the registered manager who agreed to follow this up immediately.

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 were positive about how risks were managed and mitigated. People felt involved and informed of any accidents and incidents and felt confident to raise any concerns. A person said, “I feel confident to raise any complaints, issues and feel they would be responded to.” A relative said, “I have no complaints at all, it’s a really wonderful place. There isn’t a single fault I can think of. I have always felt totally comfortable that [relation] is really safe.”

Feedback from staff confirmed what the registered manager, records reviews and observations identified. Learning and actions following incidents, accidents, safeguarding matters and complaints were openly discussed with staff. Staff felt involved and informed in how the service improved and developed. The registered manager explained how an action plan was developed following audit’s and checks that identified any areas of shortfalls. The registered manager told us how any learning and improvements were shared with the staff team. A staff member said, “We are always offered / provided with additional learning, the manager tells us about any complaints concerns, we discuss all incidents, the manager doesn’t hide anything from others, they are always open and honest.“

There was a positive and proactive approach to learning and to continually improving the service. All incidents, falls and accidents were reviewed and analysed for lessons learnt, themes and patterns. Such matters are discussed along with any complaints / concerns received or identified by the management team in the services daily 10/10 heads of department meetings, staff meetings, and daily handovers. The provider had robust audits, checks and oversight by the regional support manager and quality director. Actions plans were developed following audits and checks completed to continually make improvements. The registered manager was experienced and attended internal and external meetings and forums to share and develop practice. For example, the registered manager had registered for further training, attended local authority care home forums and completed internal manager meetings within the organisation where support and shared learning was discussed.

Feedback confirmed the provider’s pre-assessment and transition process was detailed and supportive in ensuring consistent and safe care. One person told us, “I had a visit from a staff member before moving to the service to complete an assessment. I was also involved in discussions and decisions about my care.” A relative said, “We were involved in [relation’s] pre assessment to the enth degree.”

The registered manager explained the provider’s assessment and transition arrangements. They said, “We always complete a face to face pre-assessment, we consider compatibility needs of others at the service and if there are any additional staff training, resources required before admission.” Staff confirmed, before a person moved to the service, they were made aware of their individual care and treatment needs.

Feedback from external healthcare professionals working with the service and commissioners, were positive regarding how staff worked with them to support people to achieve positive outcomes and to provide consistent care. Staff were described as being friendly, organised and knowledgeable. A professional said, “ Referrals for ward rounds are generally appropriate and timely. Staff communicate well (verbal/emails) and follow recommendations made by me. They are highly organised (commendably so) and show consistent support for my weekly visits.” Another professional said, “Staff have always been able to provide the information required. Care records including ABC records have always been found to be up to date and well recorded. Recommendations have always been actioned.”

The provider has an admissions policy dated September 2016. This policy relates overall specifically to funding arrangements, and did not include details of the pre-assessment process to ensure the person’s needs are assessed prior to admission to consider any staff training or resource needs. However, the registered manager was clear and provided assurances about the admission and discharge process in place. This included the sharing of information with other agencies for consistency and continuity of care.

Feedback confirmed people felt safe living at the service and were aware of safeguarding procedures. People told us they felt involved, and consent was sought before care was provided. One person commented, “I am very happy and feel safe to live my life here, I want for nothing, and I am very happy and content.” A relative said, “The manager has gone over all safety procedures with us, and as far as I am concerned everything seems very safe indeed.”

Staff were aware of their role and responsibilities to protect people from abuse and avoidable harm. Staff confirmed they had received safeguarding training and had access to the provider’s safeguarding policies and procedures. A staff member said, “Any unexplained bruising, altercations between people, behaviours of concern by visitors, staff not following the care plan, putting people at risk, I would record and report to the management team.” The registered manager told us about how safeguarding procedures were discussed with people and their relatives, to support their awareness. Staff showed a basic understanding of the Mental Capacity Act (MCA) principles and Deprivation of Liberty safeguards (DoLS). A staff member said, ”Principle always assume capacity. 2 stage assessment and best interest decision is completed if a person lacks capacity. DoLS - Is where a person has a restriction in place, assessments are completed by external assessors, it's a legal document.”

People were supported to understand the provider’s safeguarding procedures. Information had been made available and was discussed in resident meetings. At the time of the assessment no person required this information provided in alternative formats but the registered manager advised this would be provided if required. We observed positive engagement and communication between staff and people, where reassurance and assistance was provided in a kind manner. Staff were seen to promote people's independence. We saw some people using their walking aids safely, other people required the assistance of staff who were observed to provide this support safely, competently and were unrushed.

The provider had safeguarding and whistleblowing policy in place. Staff had direct access to these policies. Where there had been safeguarding incidents, these concerns had been reported to the relevant professional bodies where required and internal investigations and actions taken to reduce further risks. The provider policies covering the Mental Capacity Act (MCA) principles and Deprivation of Liberty safeguards (DoLS). Records reviewed identified improvements were required with how MCA assessments and best interest decisions were made. We identified some inconsistencies with how assessments were completed, and decisions made. The registered manager who commenced in April 2024 had identified this was an area for review and actions were underway to make improvements in this area.

People were confident risks were managed well and any incidents such as falls were responded to quickly and safely. One person said, “Yes I feel safe, if I'm not well or I've had a fall the staff respond quickly to help me.” A relative said, “[Relation] had a fall on Friday when my wife was with them, so they went to A&E together, it was all dealt with very well.”

Staff showed a good awareness and understanding of people’s individual risks and gave examples of how these were managed and mitigated. A staff member said, “We discuss safety with people during the monthly resident meetings. To support the risk of falls we consider trip hazards, make sure a person is wearing their glasses, has good footwear, that sensor equipment is used where required. Malnutrition risks - we offer regular snacks, fortify foods, monitor weight and raise any concerns with the GP who visits weekly.” The registered manager advised how risks were assessed and planned for and monitored. Comments included, “Care plans are updated monthly or before of details of any new / ongoing risks and actions taken to mitigate these. We have a weekly clinical risk meeting and a weekly visit by the GP.”

We observed people to be cared for safely. Staff followed guidance provided in care plans to manage and mitigate risks.

The provider had systems and processes in place to manage and mitigate risks to people. There were monthly clinical risk meetings and on-site weekly ward rounds with a local GP. The increased use of technology, observations and better analysis of themes, patterns and lessons learnt had seen a reduction in falls at the service. A sample of incident records reviewed were well documented, included the use of body maps, referral to the GP / Falls team and recommendations made by external professionals implemented. We saw evidence that risks were discussed with people and their relatives relatives at the time of the pre-assessment, development of care plans, following any type of incident and during the person's 6 month formal review. The registered manager was also implementing a 4 week review following admission. We found food and fluid charts and repositioning records followed care plan guidance. They were well documented and contained evidence of appropriate monitoring. There were some instances where the cross referencing of care plans with risk assessments was not consistently completed, and some information was contradictory. However, this was minimal and was a recording issue. Staff were fully aware of people’s needs and the potential risks. This was fed back to the registered manager for further review.

People found the environment, premises and equipment to be safe and well maintained. A person said, “The environment is of a very high standard, I can't fault it, I see the maintenance man checking things and the manager walks around every day, I assume doing their checks.“

Staff told us of the actions and ongoing monitoring of the environment to ensure safety is maintained. A staff member said, “ I check the maintenance book to make sure any jobs listed by carers are dealt with. I have ongoing processes and checks I complete daily, weekly, monthly. Any concerns can talk to the manager or go to estates.” The registered manager advised of the systems and processes that monitored the environment, premises and equipment. In addition, housekeeping staff and the chef explained their roles and responsibilities of ensuring a safe environment.

We observed the environment, premises, equipment and outdoor space to be safe, and well maintained. We observed people to be cared for safely. Staff followed guidance provided in care plans to manage and mitigate risks.

The provider had systems and processes to monitor and maintain the health and safety of the environment including premises and equipment. A maintenance member of staff was on-site daily. Risks and actions involving health and safety were discussed during daily meetings. Staff completed health and safety checks and recorded these in the daily hand over document. The registered manager also completed a daily walk around and this includes an health and safety review. Monthly governance meetings included a review of health and safety. There was an up to date fire risk assessment in place which had been updated following recommendations made by the fire service in 2023.

People told us there were sufficient, experience and competent staff who understood their care needs. Some concerns were raised about there not always being staff in reception and having to wait sometimes to be let in and out. However, we were aware a new receptionist had been appointed and the reception was now staffed 7 days a week. A person said, “Whilst staff are always around and available, you can have your privacy. It's our home.” A relative said, “There are enough staff, it’s only half full, so at the moment it’s all okay, if it were full up, I know extra staff would be employed.”

Staff confirmed recruitment checks were completed before they commenced their role. A staff member said, “ I had a face to face interview, employment history, references, DBS and right to work checks all completed before starting. I had a full week of training and shadow shifts.” Staff were positive about the ongoing training and support they received. A staff member said, “Training is good and supportive. Training is up to date, emailed when refresher is needed. This week we're having additional training in dementia care and emotional needs.” Staff confirmed they had competency assessments completed in some areas of care to ensure they were following best practice guidance and were competent. Staff were confident there were sufficient numbers of staff to meet people’s individual needs and safety. A staff member said, “No current staffing concerns, it's sufficient for the number / needs of people. Staffing is increased if a person needs supporting with an appointment, is at end of life and family are unable to support.” The registered manager and regional support manager told us how staffing levels were calculated using a dependency tool.

We observed there to be sufficient staff to meet people’s individual safety, care and treatment needs. Staff were well experienced, competent and knowledgeable about people’s individual needs. Staff were organised, attentive and responsive. Positive staff engagement was observed. Staff were kind, caring and patient, and had time to spend with people. Care and support was individual and unrushed.

The providers processes ensured there were enough suitably competent and qualified staff available to meet people's needs. There was a robust recruitment process. Staff had their competency checked in areas such as dysphagia awareness, mental capacity, deprivation of liberty safeguards and medication awareness. The provider had an up to date schedule to ensure staff received regular supervisions and an annual appraisal. The provider had a new dependency tool in place to ensure there were adequate staffing levels. Dependency needs were regularly reviewed and staffing levels adjusted accordingly.

Feedback from people confirmed they were positive about the cleanliness and hygiene of the service. A person said, “My bedroom is beautiful, and cleaned every day and clean towels and bed linen changed frequently.” A relative said, “It’s all one hundred per cent clean, very new and well designed. It’s a lovely place because it’s a new, clean, healthy and happy environment.”

Staff confirmed they had completed training in infection prevention and control and demonstrated a good understating of the measures to manage and prevent the spread of infection. A staff member said, “We have a good system, and it works for us the machines all work well, and products are good. Any concerns are taken to the morning meeting and the manager always picks them up and deals with them.” The registered manager told us of the training staff were required to complete, what audits and checks were completed to ensure good standards of cleanliness and hygiene were maintained and how personal protective equipment (PPE) stocks were managed.

Observations of the environment, premises and equipment was positive. The service was clean and hygienic with no malodour. Housekeeping staff were present and observed to be following best practice guidance in cleaning tasks. PPE was available and procedures were in place to reduce the risk of cross contamination.

The provider has a robust IPC policy and procedure. The registered manager was aware of how to manage an infection outbreak safely. Cleaning schedules daily, deep cleans were completed and there was evidence these were monitored by the leadership team. Health and safety audit included checks on cleanliness and hygiene.

Feedback from people confirmed they received their prescribed medicines safely and when required. One person told us, “I get my medication when I need it, the staff will stay with me until I've taken it, they seem very competent.”

Staff responsible for managing and administering medicines confirmed the ongoing training they were required to complete, including observations and competency assessments. Staff also told us of the procedure of ordering, storing, administering and returning unused medicines back to the pharmacy. A staff member said, “I explain to the person what they are having and why. It’s important to seek consent. We record to confirm administered. Any errors are reported straight to the management team and we call the GP or 111 and inform the next of kin.” The registered manager told us of the procedures that monitor medicines and how people’s medicines are reviewed by the GP and other health practitioners such as the community mental health team.

People received their medicines on time and as prescribed. The training matrix confirmed staff responsible for managing medicines had completed annual refresher training and a sample of competencies confirmed these assessments were robust. People were supported to self-medicate where this was requested, risk assessments and oversight procedures were in place to ensure safety. Medicines were booked in, administered and managed safely. However an issue was identified with medicine returns. A large amount of medicines were in an open container within the locked medication room. This was raised with the regional support manager and registered manager who agreed to follow up on the matter. Records showed that whilst there was reference to medicines in care records, information was sometimes limited and there was not a specific care plan for medicines. This was brought to the attention of the registered manager who agreed a separate care plan was required and agreed to action this. The provider had completed an Internal medication audit dated 1 May 2024 which had an action plan summary with 2 actions overdue.