Lakeside House Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this newly registered service. This key question has been rated requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance as quality monitoring of the service was not effective.

This service scored 54 (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 did not have a clear shared vision, strategy and culture, they told us they were working towards this to improve the service. However, this was not embedded as the leadership team was not stable due to the absence of a registered manager.

Staff did not have specific training for people with a learning disability and autistic people. As this was the core group they provided support to this meant staff were not able to learn best practice in how to support people in this area.

The provider and their staff were transparent about the lack of up to date care records and quality monitoring of the service, but without a clear plan to improve the service in place we were not assured everyone at the service was aware of the shared goals to be achieved.

The provider had inclusive leaders at all levels, however, the service did not have a manager registered with the CQC. A registered manager is a person who has registered with the CQC to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. This service is required to have a registered manager, and the recently appointed acting manager told us it was their intention to apply to CQC to become the registered manager of the service.

In the absence of a registered manager, there was limited accountability and reduced capacity to drive improvements or ensure regulatory responsibilities were met. This placed people at risk of receiving care that was not consistently well‑led.

Leaders demonstrated compassion for the people they supported and their staff team.

Staff had a better working relationship with the current acting manager and told us they could bring matters to them for action. Staff told us they spoke with the current acting manager who was approachable and patient. Staff also shared the same feedback about the director and nominated individual. Comments included, “They are easy to talk to” and “If I need anything I can go to them."

The provider fostered a culture where people felt they could speak up. Whilst this was in place staff told us they previously did not feel listened to by the previous acting manager.

Relatives knew how to make a complaint but told us they would like to be updated on their complaints. A relative said, “Recently I've had to make a complaint about [person’s] room in regards to the water stains and I have made a complaint in regard to them not telling me about the fumigation, I’m still waiting on an update for that.”

Staff knew how to speak up and were confident their concerns would be listened to. The current acting manager said, “Staff speak up about incidents, I’m confident they will raise concerns. It’s important to communicate with the team."

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The staff team was diverse and reflected the community they provided support to. Staff told us they were treated fairly and with kindness and respect.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance arrangements were ineffective. Systems intended to monitor the quality and safety of the service were either not in place or not used effectively. As a result, the provider had not identified that most care plans and risk assessments were significantly out of date and did not reflect people’s current needs. Failures in oversight also meant issues with multiple people using the same piece of equipment not assessed for their use put them at risk of avoidable harm and repairs within the home environment went unresolved for long periods. This lack of managerial oversight demonstrated a systemic failure to ensure safe, well‑led care.

Whilst the director provided mitigation on why this had happened, there was still no other mechanism to ensure oversight from the nominated individual. This could have ensured the previous acting manager was updating care records as appropriate and reporting concerns with the home environment.

The management of care records was not effective, the provider was not able to verify whether the previous acting manager had stored the records in a place that was accessible for the provider or staff to view. The provider told us they were changing how this was managed going forward, to ensure it did not happen again and staff would know where active care plans and risk assessments were held.

The provider was implementing new quality assurance procedures to improve the service, however, we could not be assured these were embedded at the end of the site visit.

Records confirmed the following audits were being completed by the service, monthly spot check, cash audit, Control of Substances Hazardous to Health and medicines audit. These did record any issues with actions to complete.

The provider understood their duty to collaborate and work in partnership with health professionals and the wider community for people’s benefit.

The provider and staff worked with health professionals and the local community to access care and support as needed. We observed people access the local community to take part in activities they liked and helped improve their emotional well being. The provider had another service close by which allowed for partner working and for staff and people to interact with each other.

The provider did not consistently focus on continuous learning, innovation and improvement across the organisation.

The provider did not have a service improvement plan in place which would support the service to improve and act on issues found. The audits in place did not allow the service to capture the concerns identified which could drive improvement and learning.