Lakeside Court ECS

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 service. This key question has been rated requires improvement. This meant governance was inconsistent and not always effective to monitor the quality and safety of the service. The service was in breach of legal regulation in relation to good governance and notification of other incidents, because incidents were not always notified to CQC as required.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The aims, objectives and core values of the service were outlined in the provider’s statement of purpose and displayed within the service setting. Staff and leaders were committed to delivering a quality service for the people they supported. The provider demonstrated respect for people’s human rights and valued diversity within the organisation. Most staff spoke positively about the leadership team and told us there was a positive culture within the service. A staff member said, “We all help each other, a tight team.”

Whilst the provider had inclusive leaders who understood the context in which they delivered care, treatment and support, and who embodied the culture and values of the organisation, leaders did not always demonstrate the skills, knowledge or experience required to lead effectively. During the assessment, the provider did not demonstrate sufficient knowledge of incidents or events requiring notification to CQC. We raised this with the provider, who assured us they would review notification requirements and share learning with the wider team to prevent recurrence. During our visits to the service, leaders were visible and supported the assessment. They were open, honest and responsive to our feedback. We received mostly positive feedback from staff regarding the management team. A staff member said, “They are available to help when we are stuck, they point us in the right direction.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Although processes intended to support staff in speaking up, such as supervision and staff meetings, were not always completed, staff told us they felt able to approach the management team informally and share any concerns. A staff member said, “Yes, I can raise any concerns.”

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 provider’s policies promoted equality, diversity, and human rights, guiding staff on best practice. Staff received equality training to improve understanding of protected characteristics and awareness of bullying and harassment. Most staff told us the management team was supportive, inclusive, and fair to all staff. Staff shared examples of how the registered manager had been flexible and supportive in relation to their health conditions and personal circumstances. One staff member said, “Couldn’t ask for better management. They completed a risk assessment before I started.”

The provider did not always 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 systems were not always effective or completed consistently. For example, audits had not addressed issues we identified with staffing, risk assessments, medicines and CQC notifications. We were not assured the system to monitor and audit people’s care visits was sufficiently robust. We identified recruitment file checklists had not been signed off by the registered manager as required. The provider told us during a period of staffing shortage, several regular audits had not been completed. The provider had recently taken action to complete these retrospectively, with support from other managers from the provider’s other services. Despite this response, the service’s existing governance processes had not prevented these shortfalls from occurring. Recent audits completed had identified shortfalls, and the provider was developing an action plan to address these. The provider responded positively during the assessment and provided assurances of actions taken to address shortfalls identified.

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 management team worked in partnership with other organisations and professionals to provide effective support and joined up care. The registered manager told us how they worked in partnership with professionals such as housing providers and social workers to coordinate packages of care and meet people’s individual needs. Professionals we contacted told us they had positive working relationships with the service. A professional commented, “Communication has been effective and professional when required.”

The provider had not always focused on continuous learning, innovation and improvement in the service. The service had been focused on increasing staff and management capacity and ensuring governance processes were completed. We found processes to share and discuss learning with staff were not being consistently completed. The response rate for the most recent people and relatives survey was low, and improvements identified had not yet been actioned. The provider responded positively to the shortfalls identified during the assessment; however, further work was needed to embed improvements and establish a consistent culture of learning, innovation and improvement. The provider showed an understanding of how to improve the service; the service had developed an action plan and was receiving support from managers across the provider’s other services to help drive and sustain the improvements.