The Lakes Care Centre

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

This service scored 57 (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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Although leaders and staff demonstrated an understanding of the importance of delivering person‑centred, high‑quality care, this was not consistently reflected in the care documentation we reviewed. Records completed about people’s care were often generic, task focused and did not consistently describe how staff should support people in a person-centred way. For example, some parts of people’s care plans such as information about people’s emotional well-being, cultural backgrounds and preferred routines were not completed or partially completed. Daily notes were mostly focusing on tasks completed rather than people’s experiences and outcomes.

As a result, the service could not demonstrate that person‑centred care principles were consistently embedded in practice, and there was a risk that people’s individuality and preferences were not fully recognised or respected.

Some concerns were also raised with us about the culture within the service. Feedback indicated that it could be difficult for staff to introduce new ideas or challenge established ways of working. One staff member told us, “Some staff have been here a very long time. I have raised some concerns about how things were being done but nothing was done about it.” Another staff member told us, “Sometimes during the team meetings when you speak up you can get backlash from other staff, especially if they have been here long.” This suggested a culture where staff did not always feel confident that their concerns or suggestions for improvement would be acted upon.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The leaders of the service had overall a good understanding of the issues and priorities within the service. There was evidence that poor practice was addressed. For example, we saw evidence that performance meetings were held with staff when their work felt short of required standards.

Staff and people spoke positively about the registered manager, describing them as responsive, visible within the service and interested in people’s welfare. One staff member told us, “Since the new manager been in post things have improved massively.” “One relative told us, “If you need to speak to the manager, you can always knock on their door.” The registered manager knew people well and was committed to ensuring the service continued its improvement journey, with identified areas for development being addressed as part of ongoing quality improvement work.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. However, this was not experienced for all people using the service and their relatives.

There were policies and procedures in place to support speaking up, and overall, both people and staff told us, they could raise concerns. However some people and staff raised concerns about effectiveness of communication, which meant opportunities to share concerns or feedback were not always clear or accessible to everyone. Some staff also told us, that at times it is difficult to propose new improvements or challenge the established ways of working.

There was evidence of regular touch points with people and staff, providing opportunities for issues and concerns to be discussed. While this supported open communication, the service would benefit from ensuring everyone understands the appropriate routes for raising concerns and accessing support.

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. However, there were still areas of improvement required.

The provider valued diversity within the workforce and was working towards an inclusive and fair culture by promoting equality and equity for staff. Policies were in place that aligned with the Equality Act and outlined the provider’s responsibilities to prevent discrimination and ensure people received care in a fair and equitable manner. The workforce reflected a range of backgrounds, cultures and experiences. However, some staff raised concerns about the culture within the service, telling us it could be difficult at times to challenge established practices or suggest new ideas. One staff member told us, “I would like to change how staff talk to each other sometimes.” This indicated that, despite positive intentions, the culture was not always experienced as open or responsive to staff feedback.

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

There was a registered manager in post at the time of the assessment. They were actively involved in the day‑to‑day running of the service and were visible and accessible to both people and staff. The registered manager demonstrated a good understanding of the service’s priorities and acknowledged several areas where improvement was still required.

Governance and oversight arrangements were in place. However, these were not always effective. Audits were not consistently comprehensive, which limited the provider’s ability to identify issues and take timely action. Lessons learned were not always clearly identified or used to drive improvements, reducing opportunities for the service to learn from incidents, feedback and emerging risks. Following our feedback, the registered manager, supported by the newly appointed Nominated Individual, planned to review current governance processes.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with a number of external partners and stakeholders to ensure that these relationships benefited the people they supported.

The provider understood the value of involving others whose expertise and knowledge contributed to improving outcomes for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There were processes and procedures in place to support a learning culture within the organisation. However, there was limited evidence that these were being used effectively to identify areas for improvement or drive progress. Completed audits and checks did not always include meaningful analysis, which restricted the insight they provided into the quality of care or the actions required. There was also very limited evidence that care was reviewed or measured against good practice standards, reducing the provider’s ability to evaluate performance and ensure continuous improvement. We discussed these concerns with the provider, and following our feedback, leaders confirmed that processes for identifying and embedding learning would be reviewed.