Lakeside Watermead Care Home

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.

This is the first assessment for this newly registered service, following a change in provider. This key question has been rated 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 regulations in relation to people’s safe care and treatment, and staffing.

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.

Lessons were not always learnt to continually identify and embed good practice.

Systems were being developed to promote a learning culture to prevent reoccurrence. However, these were not yet embedded in practice. We saw the outcome of a safeguarding investigation had concluded that the lack of robust turning charts had placed a person at higher risk of skin breakdown. On review of the person’s repositioning charts, we found they were not consistently repositioned at the frequency outlined by the tissue viability nurse. Therefore, effective monitoring of the repositioning charts was not established following the outcome of the safeguarding investigation which resulted in reoccurrence of previous failures and did not mitigate the risks to the person.

Another person had 3 falls in May 2025. Whilst no injury is recorded, the falls risk assessment was not updated to reflect the increase in falls and take measures to mitigate the risk of recurrence.These falls were not recorded as being discussed at the clinical review meetings either to promote a learning culture.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked closely with other health professionals in providing a holistic approach to people’s care. People had access to a range of health professionals including the GP, Speech and language therapists (SALT), tissue viability nurses, diabetes services and mental health teams. We saw on the rota that people who required it were supported by staff for hospital appointments. The service had access to a visiting chiropody and optician service for people.

People were not always safeguarded from the potential risk of abuse.

Staff were trained in safeguarding with policies and procedures in place to support and guide staff in their practice. We saw the outcome of an internal investigation had identified that there had been occasions where a person was not given the recommended diet to mitigate the risk of choking. Action was taken to address that, but the service failed to make a safeguarding alert and notification to us at the time. This was completed in retrospect.

In 2 people’s care plans the risks around financial abuse had not been considered. It was recorded that their bank cards were kept by the service. However, there was no system in place to safeguard people or the staff responsible for the safe keeping of the bank cards to mitigate the potential risks of financial abuse. This was addressed by the provider following our feedback to them.

We checked whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. We found systems were in place to monitor legal authorisations and renewals were completed when required.

The provider did not always work well with people to understand and manage risks.

Risks to people were not always identified and mitigated. For example, risks around distressed behaviours were not outlined with limited strategies in place to provide a consistent approach to their care. Care plans made reference to recording distressed behaviours on antecedent- behaviour consequence (ABC) charts. However, there was none in use and staff were not clear where this would be recorded on the new electronic care plan system in use in the service.

Risks associated with mental health and learning disabilities were not always identified. For a person who was a known risk of depression and self-harm there was no risk assessment to alert staff to this to ensure staff were responsive to changes in their mental health well-being.

People who were deemed a risk of skin breakdown had pressure mattresses in place. On day 1 of the inspection, we saw that for 2 people these were not set in accordance with the weight recorded on their file. By day 2 of the inspection the manager had carried out a full review of pressure mattresses against people’s weight and had taken action to ensure these were set at the required level and monitored. Alongside, this we found people were not having the required safety and repositioning checks at the frequency outlined in their care plans. The provider assured they had put measures in place to ensure prompts were set up on the electronic care plan system to remind staff and this would be included in the provider audits of care plans.

Choking risks were identified and appropriate referrals made to the Speech and Language Team (SALT). In files viewed we saw 2 people did not always comply with the SALT recommendations. It was not outlined in what way they did not comply. In 1 person’s file it was recorded that staff were to inform the nurse in charge if a person continued to refuse the SALT recommended diet. It was not clear of the expectations of the nurse in that situation to mitigate the risks to the person.

For some people at risk of choking, their care plan did not outline the level of support and supervision required with meals. Other people’s care plans indicated they ate their meals in the dining room so that staff could discreetly observe them. During the inspection we saw 2 people whose care plan indicated that due to the risk of choking they should eat in the dining room, However, during the site visit they ate in their bedrooms with minimal supervision and observation provided.

Whilst moving and handling risks were identified they were not detailed and specific to promote safe moving and handling manoeuvres. In a person’s moving and handling risk assessment it was recorded they are unable to dress themselves, get into the shower, get on and off the toilet or to transfer from the chair to toilet. However, it was not outlined how they transferred to promote their safety during personal care. For another person who received their personal care in bed the moving and handling risk assessment did not outline how personal care was to be provided or what equipment was to be used to enable them to be safely moved during personal care.

Risks to people were not always mitigated as a result of contradictions in records. We found contradictions linked to people’s weight, choking risk scores, and emotional health. These contradictions in people’s records had the potential to place people at risk due to accurate up to date information not being available to staff.

In response to our feedback the provider took immediate action to address the shortfalls in risk management to promote safe care.

People were cared for in an environment which was maintained. Whilst the provider had systems in place to ensure the service was free from potential hazards, some improvements were required to further promote a safe environment.

We found some improvements were required to ensure people were protected from fire.

Emergency evacuation plans had been written for each person, which outlined the support they would need to leave the premises. An emergency grab bag, business continuity plan and other documents were readily available, in case the premises needed to be evacuated.

Fire drills had been carried out which included the night staff. We provided some feedback to the maintenance manager about contents of the emergency fire grab bag, frequency of fire drills and information about how to evacuate people. These were acted on and addressed by the service.

A range of health and safety checks were undertaken incorporating electrical, gas and water safety. The premises were kept in good order by a maintenance manager and external contractors. Areas of the service had been refurbished and updated with further refurbishment planned. People we spoke with commented on recent improvements to the external building.

Equipment to assist people with moving had been serviced and was safe to use.

The provider responded to recommendations from risk assessments and external reports regarding safety of the building, to ensure the premises were safe. For instance, they had acted on 6 recommendations from a fire risk assessment carried out in October 2024.

We found improvements were required in the main kitchen and each dining areas where food items were stored. The microwave in the main kitchen had spots of rust on the door. On day 2 of the inspection this had been replaced.

During our walk around the service, we saw personal protective equipment (PPE) was insecure and accessible to people. There was no risk assessment in place to assure us that access to PPE did not place people at risk. In response to our feedback the provider completed a risk assessment which indicated risks were mitigated and low.

While staff were appropriately recruited and trained for their roles, with access to supervision and support being improved to benefit the people they care for, there was an issue with staffing levels. People were not provided with enough staff to meet their needs, which had a negative impact on the quality of their care.

The service had a dependency tool in place which outlined the staffing levels required on each floor. The rotas showed the required staffing levels were mostly maintained. However, we saw some staffing levels were not sufficient which impacted on people’s care. There was a delay in people receiving personal care and being supported with their meals. Their safety and repositioning checks did not occur at the frequency outlined in their care plans and staff on long days were delayed in getting their breaks.

People, relatives, and staff told us the staffing levels were not always sufficient, and people gave examples where it impacted, the time they got up and went to bed. A person commented, “The care was rushed, and often delayed.” Staff gave examples of when staffing levels had impacted people receiving timely care. For example, a person not supported with their personal care till midday.

In response to our feedback the provider confirmed they had reviewed the staffing levels, and an extra care staff member was being provided from 8;00 to 14;00 hours daily to address the shortfalls we had identified in the delivery of care. They agreed to keep the staffing levels under review.

Following our inspection, we received additional concerns about staffing levels at night, The provider investigated the concerns and confirmed that there was 1 occasion of concern. However, as this was not reported to management an additional staff member was not sourced then. As a result of the providers investigation into the allegations measures were agreed and communicated to all staff to prevent a reoccurrence.

Systems were in place to ensure staff were kept up to date with clinical skills and knowledge. A training matrix was in place which outlined staff were provided with training in a range of topics the provider considered were required for different roles. The provider had introduced competency skills checks of staff. These were underway and being completed.

We found effective induction processes were in place. The provider was unable to evidence staff were supported and supervised in line with the providers policy and procedures. However, the provider audits showed that they had identified staff supervisions and appraisals were overdue and this was being addressed.

Recruitment files contained all required checks, such as a check for criminal convictions and uptake of references. Where staff were required to have a nursing qualification and registered with the associated regulator checks were carried out to ensure staff had a license to practice as a nurse. The provider ensured all relevant information was received before an agency staff started working at the service.

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 premises were clean, and no malodours were detected. Housekeeping staff maintained high standards of hygiene throughout the service. The laundry area was well-organised, with clean and dirty areas clearly segregated to prevent the risk of cross-infection.

Staff were trained in infection control, and policies were in place to guide their practices. Infection control procedures were regularly audited to ensure compliance. Personal protective equipment (PPE) was readily available to staff whenever needed for personal care tasks.

Food items did not always have use by dates on and food storage in the freezer did not meet industry wide recommendations in relation to rotation of stock. The provider took immediate action to address our findings to ensure the shortfalls in food storage was addressed.

Systems were in place to ensure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems and processes to safely administer, record and store medicines were in place. There was clear recording of any variation on administered medicines; people were given time sensitive medicines, such as Parkinsons medicines, at the right time to ensure that they were effective; and where when required (PRN) medicines were prescribed and administered, there were records for rationale and outcomes.

Majority of care plans and PRN protocols were person-centred and contained sufficient information for staff to support people with their complex needs. We saw good examples where staff carried out additional monitoring for medicines where necessary to ensure that they were safe and effective such as regular blood glucose monitoring as per insulin protocols. People with diabetes had been fitted with sensors however glucose monitors were sometimes used for non-diabetic people, but they were not being calibrated by staff. This meant readings could be inaccurate and people might not be managed appropriately. Management was made aware and new monitors were being sourced.

People’s medicines with a limited shelf-life like liquids, creams and eye drops were dated when open and medicines that needed refrigeration were stored securely. Fridge temperatures were monitored daily and records of current, maximum and minimum were available ensuring the medicines were stored safely. However, we could not be assured the fridge thermometer was being reset by staff after each reading and so the validity of such records may be compromised. The provider confirmed and assured us that concerns about fridge temperatures had been identified and addressed by them to ensure medicines were consistently stored at the correct temperatures.

Medicines were disposed of safely when no longer required and records were kept up to date.