Archived: Ladyville Lodge

Updated 15 December 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We carried out an inspection of Ladyville Lodge on 13 November 2018. This inspection was unannounced and carried out by one inspector and one CQC colleague from legal services.

Before the inspection we reviewed relevant information that we held about the service. This included the previous inspection report, and notifications we had received. Statutory notifications are pieces of information about important events which took place at the service, such as safeguarding incidents, which the provider is required to send to us by law. We contacted other health and social care professionals for their feedback. We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection we spoke with 11 people who used the service and two relatives. We spoke with ten staff members, including the registered manager, the chef, the activities co-ordinator and care staff. We also spoke with one health and social care professional.

We reviewed documents and records that related to people's care and the management of the service including three care plans, four staff files, the staff rota, four Medicine Administration Records and service audits.

We also undertook general observations of people and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection we received additional documents to review including the business plan and policies and procedures.

Updated 15 December 2018

We carried out an unannounced inspection of this service on 13 November 2018. Ladyville Lodge provides accommodation and nursing care for up to 38 older people who have nursing or dementia care needs. At the time of our inspection 34 people were living at the service.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. This service provides personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service has a registered manager in post. 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.

At our last inspection on 26 September 2017 the service was rated 'Requires Improvement'. We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found inconsistent practices in relation to infection control and the maintenance of equipment. At this inspection we found that this breach had been addressed. Therefore, we rated the service as ‘Good .’

People using the service and their relatives said they felt the service provided safe care and treatment. People were protected from the risk of infection. There were procedures in place to protect people from harm and staff were clear on how to recognise and report abuse. The service assessed and managed risks to people in a way that considered their individual needs. We found that ‘personal emergency evacuation plans’ (PEEP) were not readily available; a recommendation was made for the provider to ensure they follow best practice guidelines to keep people safe at all times. Recruitment systems were robust and staff had been recruited safely with appropriate checks on their backgrounds. There were sufficient numbers of staff employed by the service. The service managed medicines safely. Accidents and incidents were evaluated to continuously improve.

The service completed pre-admission assessments to ensure the service could offer them the best support. Staff received a thorough induction, undertook regular training and received regular supervision to enable them to feel supported to provide effective care. People were encouraged to live a healthy lifestyle and received holistic support from various health and social care professionals. The service had been designed and adapted with people’s preferences and support needs in mind. Staff understood the Mental Capacity Act 2005 (MCA) and gained consent before providing care and support. MCA is law protecting people who are unable to make decisions for themselves and where people were not able to do this, the appropriate authorisation procedures had been completed. These are referred to as the Deprivation of Liberty Safeguards (DoLS).

People were protected from potential discrimination and staff understood the principles of equality and diversity. However, there was no information available about people’s sexuality or relationships. A recommendation was made for the provider to ensure they follow best practice guidelines and support people to safely express their needs and receive safe care.

People and their relatives told us staff treated people with dignity and respect and confidentiality was maintained. People were supported to be as independent as possible. People and their relatives felt involved in the running of the service and could have an input into the care and support provided.

Each person had an individual care plan that reflected their support needs and were regularly reviewed. The service held a variety of meaningful activities to ensure people were engaged. The service welcomed people raising any issues they might have about the service and there were systems in place to respond to all complaints. The service supported people with their end of life wishes.

Staff felt valued and supported by the registered manager who was approachable and knowledgeable. The service demonstrated an open and supportive culture. Feedback was gathered from people, relatives, health and social care professionals and staff to assess, monitor and improve the quality of the service. Regular audits and spot checks were carried out to ensure people were receiving safe and effective care and support. The registered manager received support at provide level to ensure the service was well-led.