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Inspection Summary

Overall summary & rating


Updated 11 September 2018

The inspection took place on 14 August 2018 and was unannounced. The last comprehensive inspection took place in August 2017, when we identified four breaches of Regulation. People did not always receive care and treatment which was person-centred and met their needs. The registered provider was not always doing all that was reasonably practicable to mitigate risks associated with people’s care and treatment. Systems and processes in place to monitor and improve the quality of the service, were not effective and needed embedding into practice. There were insufficient numbers of staff to keep people safe and to meet their needs. The service was rated as Requires Improvement.

Following the last inspection, we asked the registered provider to complete an action plan to show what they would do to improve the key questions safe and well led, to at least Good.

At this inspection we checked if improvements had been made. We found that the registered provider had addressed all the concerns raised at our last inspection and the rating of the service improved to Good. You can read the report from our last inspections, by selecting the 'all reports' link for ‘Ladyfield House’ on our website at

Ladyfield House is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Ladyfield House provides accommodation for up to 50 people. The home consists of two separate units; Salvin and Hewitt. The service provides accommodation for people who require personal care, including people living with dementia. The home is located in the Kiveton Park area of Rotherham. At the time of our inspection there were 35 people using the service. This included people who were staying at the home for a short period of respite care.

At the time of our inspection the service had a registered manager. 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.’

People were safeguarded against the risk of abuse. Staff confirmed they had received training in the subject and knew what action to take if they suspected abuse.

Risks associated with people care were identified and managed appropriately. Risk assessments were in place to guide staff in ensuring risks were minimised.

We observed staff interacting with people and found there were enough staff available to meet people needs. However, whilst most people we spoke with felt there were enough staff available, a minority of people told us there were not enough staff at busy times. Staff were recruited in a safe way, which ensured that suitable people were working at the home.

People’s medicines were managed in a safe way and people received their medicines as prescribed.

Staff had the skills and knowledge to deliver effective care. People were supported to maintain a healthy, balanced diet which meant their needs and preferences. People had access to healthcare professionals and their advice was followed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The service was compliant with the Mental Capacity Act 2005.

During our inspection we found staff interacted well with people who used the service. Staff were kind and caring in their manner, knew people well and provided a homely atmosphere.

We looked at care records belonging to people who used the service and found evidence that staff were responsive to people’s needs.

Social activities and stimulation was available throughout

Inspection areas



Updated 11 September 2018

The service was safe.

Risks associated with people’s care and treatment were identified and managed safely.

Accident and incident analysis had taken place and there was evidence that trends or patterns were being identified and actions taken to reduce hazards in relation to people's care.

The registered provider ensured that safe arrangements were in place for managing people’s medicines.

Staff were knowledgeable about safeguarding people from abuse.

The registered provider had a safe recruitment system in place.

There were enough staff available to meet people’s needs.



Updated 11 September 2018

The service was effective.

The registered provider ensured that staff received appropriate training and support to carry out their role.

People’s needs and choices were assessed and care and treatment was delivered in line with current legislation and standards.

The registered provider was meeting the requirements of the MCA 2005, for the majority of people’s care.

People had access to healthcare professionals when required.

People received support to maintain a balanced diet. Meals provided were nutritious and looked appetising.



Updated 11 September 2018

The service was caring.

We spent time observing staff interacting with people and found they were kind and caring in nature.

Information about people was kept confidential.

We saw staff respected people’s privacy and dignity when offering support.



Updated 11 September 2018

The service was responsive.

We found people received care that was responsive to their needs.

A varied program of social activity and stimulation was available.

All the people we spoke with knew how to raise a complaint and said they felt comfortable speaking with the staff team.



Updated 11 September 2018

The service was well led.

Audits were in place to ensure the service was operating in line with the registered providers expected standards. Audits identified areas of improvement which were dealt with.

The registered manager held meetings with people who used the service and their relatives to offer a forum where discussions could take place.