Ladyfield House

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Recent concerns had been brought to the attention of the management team, and they had taken action to improve systems based on lessons learned. Accidents and incidents were analysed, and trends and patterns were identified to mitigate future occurrences.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. The management team told us there were systems and processes in place to ensure people received the care they required. The registered manager told us daily flash meetings helped in identifying changes in peoples care and support. However, these systems required further embedding in to practice to ensure important information was shared in a timely way.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. We observed staff interacting with people safely, ensuring support was delivered in line with people’s care plans. The management team had taken action to refer safeguarding concerns in a timely way. Relatives felt their family members were safe living in the home. One relative said, “[Family member] is absolutely safe and is getting all the attention they need.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people’s care had been identified but not always managed to keep people safe. Some care plans and risk assessments were not always reflective of people’s current needs. For example, where people required staff support to reposition them, this had not always been documented clearly.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider could evidence that routine maintenance, and checks had been carried out in a timely way. Servicing of equipment used in the home had been completed in line with the servicing requirements.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, they did not always work together well to provide safe care that met people’s individual needs. During busier periods some people were left waiting for support. We received mixed comments from people and their relatives. One person said, “There are not enough staff really,” but another person said, “Staff are very well organised.” Staff were recruited safely, felt supported and told us they received appropriate training to carry out their roles well.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home was generally clean and tidy, however, some armchair seating cushions and toilet frames required attention. The registered manager took appropriate action to address these concerns, but these issues had not been identified as part of the providers governance systems.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Administration of controlled drugs was not always signed by 2 staff and body maps for the administration of pain patches were not used effectively. This put people at risk of harm. People who required medicines prescribed on an as and when required basis, often referred to as PRN, had protocols in place to ensure safe administration. People told us they received their medicines as prescribed. One person said, “You always get your medicines on time.”