Lakenham Residential Care Home

Lakenham is a residential care home providing accommodation and personal care to 19 people in one adapted building at the time of the inspection. The service can support up to 25 people.

People’s experience of using this service and what we found

Staff were deployed appropriately within the home to meet people’s needs in a timely manner.

People said staff were kind and compassionate in their approach. One person commented, “They (staff) are wonderful, they have the right attitude.” Relatives commented, “The staff are lovely” and “The staff go over and above to make residents feel at home, happy and secure. Mum has taken a little while to settle in and their patience and professionalism have really helped. The manager (manager name) inspires me with confidence, along with her team. (Staff names) are respectful and kind to residents. The atmosphere there is happy and relaxed. I enjoy visiting!”

The provider was actively recruiting for staff on an ongoing process via various advertising sources. There were effective recruitment and selection processes in place.

People’s individual risks were identified, and the necessary risk assessment reviews were carried out to keep people safe. For example, risk assessments for falls, skin care, eating and drinking and pain management. Risk management considered people’s physical and mental health needs and showed that measures to manage risk were as least restrictive as possible.

Since our last inspection comfort charts had been introduced where appropriate and handover documentation was more robust to ensure people’s risks were managed safely, consistently and in a timely manner.

People said they felt safe with staff; staff practice showed they knew them well. A person commented, “I feel really safe here, the staff look after me. I have no concerns.” People were at ease and looked comfortable in the company of staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We found the service was working within the principles of the Mental Capacity Act and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met.

People’s medicines were managed so they received them safely. Infection control measures were in place.

The service sought feedback from people who use the service to identify areas for improvement. In response to a change in management in the service and feedback there was a greater emphasis on ensuring people received person-centred care. For example, people developing their life stories in order for care and support to be more personalised according to them as individuals.

People’s equality, diversity and human rights were respected. The service’s vision and values centred around the people they supported. The organisation’s overall statement documented a philosophy of maximising people’s life choices, encouraging independence and people having a sense of worth and value. Our inspection found that the organisation’s philosophy was increasingly being embedded in Lakenham Residential Care Home. For example, people were constantly encouraged to lead rich and meaningful lives to aid their physical and mental health well-being.

A number of methods were used to assess the quality and safety of the service people received. The service made continuous improvements in response to their findings.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 21 October 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended the provider documented interview questions and answers to further strengthen recruitment practices within the home and strengthened medicines administration practices in line with best practice guidance. At this inspection we found the provider had acted on these recommendations and improvements had been made.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 19 August 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person-centred care, safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lakenham Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Lakenham Residential Care Home is a residential care home providing accommodation and personal care to 23 people in one adapted building at the time of the inspection. The service can support up to 25 people.

People’s experience of using this service and what we found

At the time of our inspection, several people were being cared for in their bedrooms because five people had a chest infection, which was not COVID-19 related. They were isolating to prevent the spread of infection. As a result, it took a long time for everyone to receive their meal at lunchtime as staff were having to change how lunch was served, which required a different approach to the deployment of staff. We observed that some people were waiting for their lunch for up to 45 minutes, which resulted in their food being cold and unappetising. We raised our concerns with the manager and provider, who admitted this was not at all acceptable and they would address the shortfalls as a matter of priority. By the second day of our inspection, two warming plates had been ordered to ensure food remained at the right temperature.

On the first day of our inspection, we observed a person in a bedroom a distance away from the others. The door was closed, and they had no call bell so could not be heard if needed assistance. There was no television or radio on for company. The person’s legs were not elevated, and they had no covering on their legs or feet and we were unsure when they last had a drink or had eaten. We were unable to establish when they had last been checked on by staff. We raised this with the manager, who informed us that normally the person would spend their days in communal areas, but today this had not happened and that it had been an oversight due to short staffing.

We asked them to address these concerns as a matter of priority, which they agreed to do. We received an email the following day from the provider who had held a meeting with staff about the importance of people being regularly checked and ensuring they have fluids available to them. They also informed us that the person had received appropriate support as cited in daily records. By the second day of our inspection, comfort charts were now in place for staff to complete to ensure regular checks on people in order for their needs to be met in a timely manner.

No one had any pressure damage at the time of our inspection. However, mattress settings were not being checked in line with people’s weights to ensure people’s skin integrity. As a result, by the second day of our inspection individualised weight charts had been implemented which indicated the setting for the mattress and these checks were added to the comfort charts to ensure people were receiving safe care and support.

Medicines were safely administered. Medicines administration records were appropriately signed by staff when administering a person’s medicines. However, we found gaps in the controlled drug book, which require double signatures when these medicines are administered. There were four occasions when this had happened, with only one staff member signing. The deputy manager informed us that they were chasing up and reminding staff to ensure they signed appropriately the administration of controlled drugs. Audits were undertaken to ensure people were receiving their medicines as prescribed. The checks also ensured medicines remained in date. However, these audits had not picked up the issues we found with the signing of controlled drugs.

We have made a recommendation to further strengthen medicines administration practices in line with best practice guidance.

Staff were recruited safely, and appropriate checks were carried out to protect people from the employment of unsuitable staff. However, despite interviews and discussions regarding gaps in employment history taking place, these were not documented.

We have made a recommendation to further strengthen recruitment practices within the home.

There was a range of quality monitoring systems in place which were used to continually review and improve the service. However, the audits did not pick up on our concerns raised in relation to people not receiving person-centred care which met their needs and reflected their personal preferences, people not receiving care and support in a safe way and medicines management as detailed in the safe domain. These concerns were addressed by the service once we raised them.

A new manager was in post and was developing their skills to become the registered manager. To further develop their skills, they were working with the local authority Quality Assurance Improvement Team (QAIT). The QAIT team offers advice and support to providers to meet the quality standards and requirements of regulators and local authority. This would also enable them to further develop robust audits to ensure the quality and safety of the service.

People told us they felt safe living at Lakenham Residential Care Home, and that staff were kind and caring. Concerns raised with the manager and provider regarding people’s specific care and support needs were addressed by the manager and provider in a timely manner.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff had received up to date safeguarding training in order for them to understand what good practice is, how to report concerns and keep people safe. Staff knew the procedure to follow if they witnessed abuse. Policies and procedures relating to safeguarding reflected current best practice and provided staff with the relevant details should they wish to raise a concern outside of the organisation.

The management and staff had people’s safety and wellbeing as their focus. Risks associated with people's health and wellbeing were assessed prior to admission and on an on-going basis once resident in the home. Where risks were identified, there was guidance in place to reduce the risk of harm. Care plans contained information in line with and addressed people’s assessed needs, and how to reduce or prevent them. This enabled clear oversight and enabled changes in a person’s physical or mental health to be escalated, including to the community nursing team.

Mental capacity assessments had been undertaken specific to additional measures required to keep people safe. For example, regards to the need for a pressure mat to be in place due to a person’s risk of falls.

There was evidence that learning from incidents and investigations took place and appropriate changes were implemented. For example, when a person’s physical health needs had changed, their care plans and risk assessments had been updated and involvement of other health and social care professionals was requested in a timely way.

Staff told us they were short staffed on occasions but were confident it was a safe service. They were doing the best they could to ensure people had their care and support needs met, picking up extra shifts when needed. The provider and manager confirmed they had experienced difficulties with staffing, largely due to staff leaving, recruitment difficulties, last minute staff sickness and staff needing to self-isolate. They were working to address this and provide a safe service. The provider was actively recruiting for staff on an ongoing process via various advertising sources.

We were assured that infection prevention and control measures were sufficient and in line with current UK government guidance.

A system was in place to record complaints. Complaints were acknowledged and responded to in an appropriate time frame and other professionals informed and involved where appropriate.

We continue to receive statutory notifications in relation to safeguarding events and serious injuries in a timely manner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 5 October 2017).

Why we inspected

We had received concerns around new admissions processes and the home’s ability to meet people's specific care and support needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We inspected and found there were concerns in relation to person-centred care, safe care and treatment and governance arrangements. Please see the Safe and Well-led sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lakenham Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice:

Staff were aware of the correct personal protective equipment (PPE) they needed to wear to keep people and themselves safe.

Right from the offset of this pandemic the provider used their contacts to ensure the staff team had a good supply of PPE.

The provider gave staff a box of gloves and masks for use outside of the service to keep themselves safe when shopping, for example. They had been encouraged to wear these before masks became mandatory by the government.

Staff were observed wearing PPE throughout the building and throughout the inspection.

Staff had training and support to understand the fundamentals of infection control and Covid 19. There was a contingency plan for if the service had an outbreak.

All visitors were only allowed into the home once they had declared their health status, provided their contact details and had their temperature checked. Most visits were via prior appointment.

Visits from family members had been via window visits and contact via phone and video calls. The exception being for people who were at end of life care. In this instance, family were supported to visit. This was done with full PPE provided and testing of those who would be visiting.

Cleaning schedules had been increased to ensure high touch points were being cleaned. This was not being recorded. Following feedback the registered manager gave assurances this would be implemented immediately.

Lakenham Residential Care Home is a care home which provides care and support to older people some of whom have been diagnosed with a form of dementia. The home does not provide nursing care. The home had previously been able to accommodate 28 people. The provider had applied to the Care Quality Commission (CQC) to reduce this to 25 people. In May 2017 the provider had been issued with a new registration to accommodate 25 people at the service. There were 20 people using the service on the first day of the 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.

We had previously carried out a comprehensive inspection of this service in July 2016. A breach of a legal requirement had been found at that inspection. The breach was because care plans did not always include details relevant to maintaining people’s health and wellbeing. Also people and their families had not been involved in developing and reviewing their care plans. Following the inspection we were sent an action plan setting out the actions the provider was going to take. At this inspection we found action had been taken regarding these concerns and the requirement had been met.

The registered manager had worked with staff and put in place very comprehensive care plans. Care plans reflected people’s needs and gave staff clear guidance about how to support them safely. They were personalised and people where able and their families had been involved in their development. Therefore people received personalised care that was responsive to their needs.

Risk assessments were undertaken for people to ensure their health needs were identified. Accidents and incidents were reported and action was taken to reduce the risks of recurrence.

Everyone gave us positive feedback about the registered manager and said they were very visible at the service and undertook an active role. They promoted a strong caring and supportive approach to staff.

People were supported to follow their interests and take part in social activities. A designated activities coordinator was employed by the provider. They ensured each person at the service had the opportunity to take part in activities and social events which were of an interest to them.

Staff were able to anticipate people’s needs and were respectful, discreet and appropriate in how they managed those needs. There were positive and caring relationships between staff and people who lived in the home and this extended to relatives and other visitors. Staff were compassionate, treated people as individuals and with dignity and respect. Staff knew the people they supported, about their personal histories and daily preferences. Staff showed concern for people’s wellbeing in a caring and meaningful way. Where possible, people were involved in making decisions and planning their own care on a day to day basis.

The registered manager and staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) (2005). Where people lacked capacity, mental capacity assessments were completed and best interest decisions made in line with the MCA for the majority of decisions.

People were supported by sufficient staff to meet their needs promptly. Staff had the required recruitment checks in place and were trained and had the skills and knowledge to meet their needs. Staff had received an induction and were knowledgeable about the signs of abuse and how to report concerns.

People were supported to eat and drink enough and maintain a balanced diet. People were seen to be enjoying the food they received during the inspection.

Medicines were safely managed and procedures were in place to ensure people received their medicines as prescribed.

People were referred promptly to health care services when required and received on-going healthcare support. Healthcare professionals were positive about the quality of care provided at the home and the commitment of the team to provide a good service.

The premises were managed to keep people safe. The home was clean and had a nice atmosphere although there were some area of the home looked tired. The There were emergency plans in place to protect people in the event of a fire or emergency.

The provider had a quality monitoring system at the service. The registered manager actively sought the views of people, their relatives and staff. This was through regular staff meetings, being very active within the service, surveys and a comments book to continuously improve the service.

There was a complaints procedure in place and people were confident any concerns they raised would be looked into.

Lakenham Residential Care Home is a care home which provides care and support to older people some of whom have been diagnosed with a form of dementia. The home does not provide nursing care. The home can accommodate up to 28 people. There were 22 people using the service at the time of the inspection.

The service is required to have 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. Lakenham Residential Home had a registered manager.

Our previous scheduled inspection of Lakenham Residential Home, in September 2015, found the provider had failed to protect people who used the service. This related to ensuring a safe premises, the handling of medicines, consent to care and treatment, deprivation of liberty without authorisation, not notifying the Commission of incidents, assessment of risk and insufficient oversight of the service to maintain safety and promote welfare. Following the last inspection, the provider sent us an action plan. Following this a focused inspection in March 2016, to look at medicine management, found that there was significant improvement but not all risk had been managed. This inspection found that medicine management was safe and there was a lot of improvement with regard to protecting people who used the service, although not all of the improvements were completed or embedded.

People’s legal rights were understood and being promoted although where people had authorised a representative to act on their behalf the detail of those authorisations was not always confirmed. Some of those details were noted, but further improvements were needed

People enjoyed the meals provided but the service were unable to evidence the diet people received was nutritionally balanced. This was because there was no set menu and the cook had not received training in the subject. We have recommended that the service uses current, researched based, best practice in providing nutritious diets for people living with conditions relating to older age or disability.

Whilst Lakenham Residential Home provides a wide variety of communal space there were no environmental adaptations to promote independence for people living with dementia. We recommend the providers consult current guidance on the design of environments for people living with dementia and take that guidance into account for any future upgrading.

An effective recruitment policy protected people from staff who might be unsuitable or unsafe to work in a care home. However, we recommend a review of the service recruitment policy to ensure all aspects of the recruitment procedures are recorded.

Some care plans lacked the detail to ensure people’s needs were fully understood and planned for. Some staff recording showed a lack of understanding in how to respond to a change in people’s needs. Some risk management was reactive to a problem rather than based on continual assessment and response. However, people’s needs were being met.

Staffing arrangements promoted people’s safety although some people felt the staff were sometimes unable to respond as they would have wished.

People, their family members, staff and health care professionals commented positively about the improved management and standards of care at the home.

People described a caring, friendly, patient and compassionate staff team.

Staff received the training, support and supervision needed to do their work. The registered manager monitored and worked with staff to improve their practice and find ways of improving people’s lives. The staff worked with community professionals for advice and to improve safety for people.

People said they were confident any complaint would be listened to and followed up. The quality monitoring surveys used at the home were being reviewed; people could make their views known.

The order of improvements at the home was based on risk.

We found one breach in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). You can see what action we asked the provider to take at the back of this report.

Lakenham Residential Care Home is a care home which provides care and support to older people some of whom have been diagnosed with a form of dementia. The home does not provide nursing care. The home can accommodate up to 28 people.

The service is required to have 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. There was no registered manager in post but a new manager was recently appointed. They said they were starting their application to register with the Care Quality Commission.

Our previous inspection, September 2015, found that medicine management at Lakenham Residential Home, was not safe. We issued a warning notice. During this inspection, we found that improvements had been made to address the areas of concern in the warning notice.

Staff had taken action to improve the ordering system to reduce the risk of medicines being out of stock. Staff recorded the receipt of medicines into the home so it was possible to check that administration records were accurate. People we spoke to did not have any concerns about how staff looked after their medicines.

Medicines training had been provided for staff to help ensure staff followed safe practice.

Some further action was needed to make sure that people’s medicines were looked after and given safely.

There was no additional information available to staff when people were prescribed medicines to be given ‘when required’, to help them give these medicines in a safe and consistent way.

There was no formal system to check that staff continued to give medicines safely. This increased the risk of unsafe practice continuing.

There were a continued breach of regulation. You can see what action we told the provider to take at the back of this report.

This is a summary of what we found-

Is the service safe?

We felt that the service was safe.

People told us they felt safe living at Lakenham Residential Care Home.

We found Lakenham Residential Care Home to be clean and there were no unpleasant odours.

On the day of our inspection there were 14 out of 24 people living at the care home.

We assessed the staffing numbers of the home, which showed that there was sufficient staff on duty to meet people's needs throughout the day.

We found that people's care plans contained risk assessments to support staff to reduce and prevent a risk to the person or to themselves.

Is the service effective?

We did not find that the service was effective.

People who lived at Lakenham Residential Care Home were complementary of the care and support they received and told us, staff were 'kind', 'caring' and 'respectful'.

People we spoke with told us they did not feel that there was enough to do, one person commented, 'There could be a bit more going on'.

We found people's dignity was not always respected whilst being assisted with meals.

There was no evidence in people's care plans that the person and or their relative/representative had been involved in the creation of their care plan.

People were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medication.

Is the service caring?

We found the service to be caring.

People who lived at Lakenham Residential Care Home told us staff were kind and caring. Comments included, 'first class, it really is' and 'we are well looked after'.

During our inspection we found staff to be attentive to people's care needs and request for assistance.

We found staff engaged in friendly conversation with people, however, we observed at times staff spoke with people in a childlike manner. Although, this was not with any unkindness, it was not respectful to people.

Is the service responsive?

We found the service to be responsive.

We found in people's care records that staff involved external health care professionals such as dieticians and psychiatric nurses to support people with their changing care needs.

During our inspection we observed staff responding to people's need when requested.

We found that when a complaint was received the provider fully investigated the concerns and when requested, liaised and worked with the local authority and the Commission to resolve concerns. We saw that the provider used complaints to implement changes as necessary to improve the standards and quality of the care delivered.

Is the service well-led?

We found the service to be well-led.

The service did not have a manager who was registered with the Care Quality Commission; however, we were informed that an application was being made.

It was clear from our observations that the provider and managers were actively involved in the care and support of people who lived at Lakenham Residential Care Home and they were passionate about ensuring people received good care.

Staff we spoke with told us they enjoyed working at Lakenham Residential Care Home and told us they felt the provider and head of care were supportive and approachable. Staff told us training was important to the provider and that training was reflective and responsive to the areas which staff required to improve or refresh their knowledge.

We found the provider did not have effective systems in place to monitor the quality of the service being provided. We found the monitoring of medication and the environment required improvement.

We made this visit because we had received information about Lakenham Residential Home. We were told that there were not enough staff in the home, that staff were expected to work singly when two staff were needed for safe achievement of tasks and that necessary equipment was faulty. During this visit we found that the provider was taking action to provide sufficient staffing. We found that staff were working together in a safe way. New hoists had been purchased. The provider undertook to admit no more people to live in the home until staff recruitment had been achieved to ensure no further increase in caring responsibilities for staff.

One person told us, 'Staff are first class, I have no complaint. Meals are good and varied. I could have a bath or shower every day if I wanted.' One health care professional said, 'I have had no problems. Staff always contact us if there are concerns with our patients. All has been going well at Lakenham for the people we have been working with.'

We spoke with six people living in the home and were able to observe four others. We met with the provider, the unregistered manager, three staff on duty and two regular visitors to the home. We toured the home and looked at care records and other documents related to the running of the home.

One person told us 'the staff are very helpful. They always check on me before I go to sleep to make sure I am alright and see if there is anything else I want.'

We found that people were being given food that was appropriate for them and that staff knew when they were not eating and took appropriate action. People enjoyed their meals and were given food that was suitable for their health conditions and their ability to eat.

We found that staff had the equipment they needed to maintain good hygiene. We found the house was clean and free from unpleasant odours. Staff were responsible for cleaning the rooms of the people whose care they had provided. We saw that staff worked very hard to achieve this as they were answering call bells and watching for the safety of people living in the home.

Before people received any care or treatment they were asked for their consent and staff acted in accordance with their wishes.

People we spoke with who lived at the home said that their care and welfare needs were being well met. Comments included: 'I love it here, we can see the sea'; 'They (the staff) always ask if they can help me, they help me with anything' and 'My needs are always met, I have no grumbles.'

Medicines were safely administered. We saw the medication recording records which were appropriately signed by staff when administering a person's medication.

We observed that staff were well organised, motivated and competent in their roles. Staff provided support in a caring manner making sure that people were comfortable and content.

People were made aware of the complaints system. This was provided in a format that met their needs. Comments included: 'I have no concerns, but would speak to staff if I had' and 'I have no grumbles.'