Lakeside Court ECS

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 service. 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 regulation in relation to staffing.

This service scored 50 (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 always have a proactive and positive culture of safety; incidents were not always appropriately reported. Lessons learnt were not always well documented and shared to embed good practice. The provider had processes to identify and record accidents and incidents; however, systems for reviewing records for trends, patterns, and sharing learning were not completed consistently. The provider told us there had been a staffing shortage since August 2025, affecting care staff and management capacity within the service. As a result, several management processes, including audits and incident oversight, had not been kept up to date. We identified several incidents which had not been notified to the Care Quality Commission (CQC) as required. Accidents, incidents and complaints were documented, with staff receiving messages via an electronic care planning system to update them on changes and areas where improvements were required. However, processes to support discussion and learning within the staff team were not being consistently completed. For example, staff supervisions had not been kept up to date, and staff meetings were not held on a regular basis. Despite these shortfalls, staff we spoke with understood their responsibilities to record incidents and monitor people to ensure their safety. People and their relatives told us they felt able to raise any concerns. A relative said, “The company is well organised and approachable.”

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. When people received support from different services, the provider helped to maintain continuity of care. People’s care records included a grab sheet, which provided key information about their care and support needs in the event of an emergency. The provider had policies and procedures to support staff with new referrals and when working alongside other professionals. Professionals we contacted told us they had good communication and positive working relationships with the service, which supported continuity of care for people. A professional commented, “The provider, is very open and works collaboratively with us to address any issues that arise.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. During the assessment, we identified several safeguarding referrals had not been notified to CQC. This is a legal requirement. We raised this with the provider, who told us this was an oversight. Following the assessment the notifications were submitted. We found not all staff had refreshed their safeguarding adults training in line with procedure. The service had an appropriate safeguarding policy providing guidance for staff on how to safeguard people from abuse. Staff made appropriate referrals to the local authority in response to safeguarding concerns, investigations were completed, and actions were taken to reduce risk. People and their relatives told us they felt safe living at the service. A person said, “I feel very safe in their care.”

The provider did not always work well with people to understand and manage risks. The provider had systems and processes to assess and monitor people’s risks; however, these were not always effective. We identified some risks had not been sufficiently or consistently assessed, for example in relation to catheter care and diabetes. Some risk assessments had not been reviewed within the past year, and we identified information which had not been updated. The provider told us they were aware of gaps in risk assessments and the need for care plans to be reviewed following the completion of recent audits. Despite these shortfalls, staff we spoke with demonstrated an understanding of people’s risks and told us care records contained sufficient information to support safe care. Professionals told us they felt risks to people were well managed. A professional said, “Risks appear to be identified appropriately and managed proportionately, with consideration given to promoting independence while ensuring safety.” The service recognised people’s strengths and supported them to take positive risks, including administering their own medication and participating in activities and outings.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.The provider had a process to assess health and safety risks to people and staff working in people’s homes; however, we found staff had not completed this process for some people, and records for others had not been reviewed. The provider was not responsible for managing or maintaining the premises where people received care and support. However, the system used to monitor the servicing of people’s mobility equipment wasn’t robust enough to provide managers with effective oversight. The provider told us they would address these issues, and during the assessment they confirmed health and safety risk assessments were now completed for all people using the service.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. During a period of staffing shortage, we were informed the registered manager and other office‑based staff spent part of their usual working hours and additional hours covering people’s care visits. As a result, management processes, such as those related to staff support and audits, had not been kept up to date. For example, induction records were not completed for new starters, and most staff supervision, appraisals and competency assessments had not been completed or kept up to date. Staff training records had not been kept up to date. Some areas of training had not been completed or refreshed for several staff, including training required to meet individual needs, such as dysphagia, diabetes and dementia. We were not assured the system to record and monitor people’s care visits was sufficiently robust. Actual care visit times were not always recorded by staff, and records showed some late care visits which had not been identified by the provider. Audits of care visits during this period were not consistently completed.

We received mixed feedback regarding staffing within the service. Overall, most people and their relatives spoke positively of the support provided by staff; however, concerns were raised about the impact of a staffing shortage. A person said, “I am happy with the care. They are angels.” Another commented, “There are not enough staff, which can affect my care.” A relative said, “I find the carers up and down to be honest. A staff shortage due to turnover really rocked the boat. The staff were really unsettled and efficiency went down. I think this is because of management not developing a good contingency plan for staff absences.” A professional commented, “The expectation of senior members of staff working excess hours to cover shifts has become an increasing concern.” Most staff we spoke with said they felt supported and had taken on additional shifts to help provide cover; however, the staffing shortage was challenging and meant some care visits were cut short. A staff member said, “It could improve with more staff. We still give the full care we can possibly give; some calls are cut short. It’s not ideal. We are crammed with all the calls.” The provider told us they were aware of the issues, had a business continuity plan in place, staffing capacity was improving across the service, and they had recruited an additional manager who was due to start. Staff recruitment records we reviewed were satisfactory, with all relevant checks completed before staff began working at the service. These included criminal record and employment history checks to confirm suitability for the role.

The provider did not always assess or manage the risk of infection. The provider had processes to assess and manage the risk of infection; however, they were not being consistently completed. Not all staff had refreshed their training in infection control or had their annual competency assessment completed, which included spot checks on infection control practice. Health and safety risk assessments, which included an assessment on infection control risks had not been completed for some people, and for others the records had not been reviewed. Care plans contained guidance for staff on appropriate use of Personal Protective Equipment (PPE) and how to access and dispose of it. People and their relatives did not raise any concerns in relation to infection control, and staff confirmed they had access to sufficient PPE. During the assessment, the provider informed us they had taken action to complete staff competency assessments and health and safety risk assessments.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We identified areas where staff did not consistently follow procedure or national guidance. For example, protocols for PRN ‘as required’ medicines were not always available to guide staff. The rotation of pain patches was not clearly documented, and some staff had not completed or refreshed required medicines training or competency assessments. The provider told us completion of medicines audits had fallen behind due to a staffing shortage and had recently been completed retrospectively by managers from the provider’s other services. Completed audits highlighted areas for improvement; however, they had not resolved the issues we identified. Despite these shortfalls, people and their relatives told us they were satisfied with support provided with medicines. One person said, “They come in 7 days per week, twice a day to give me my medication.” People’s needs relating to medicines support had been assessed, with evidence of their involvement in the process. Care records included information about people’s medicines, such as level of support required, safe storage, methods of administration, and risks.