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Inspection Summary

Overall summary & rating


Updated 17 April 2018

This inspection took place on 8 and 9 February 2018 and was unannounced. It was the service’s first inspection since registering with the Care Quality Commission (CQC) in March 2017.

The Lakes Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate 64 people across four separate units, each of which have separate adapted facilities. At the time of the inspection 23 people lived in two units (two further units were not yet used). The home specialises in meeting the needs of those who live with dementia but also meets people’s physical health needs.

Accommodation for people comprised of single bedrooms with private toilet and washing facilities. All bedrooms were provided with bedroom furniture, a window and heating. Each unit, called a household, had its own dining and kitchen area with communal lounges. Additional toilets and adapted bathrooms were also available on each unit. On the ground floor another communal area was used for activities. This was also the home’s in-house tea/coffee room.

There was not a registered manager in position. A newly appointed home manager was however in post and they had started the application process to be the registered manager of the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The home had lacked consistent management and effective leadership for some time. Challenges from this had arisen, which the new managers had a good understanding of and were addressing. At the time of this inspection the home was being well-led and strong leadership was being provided. On-going quality monitoring of the services provided was in place and from this identifiable improvements had already taken place. The new managers were in control of the service and a more robust management structure was emerging. Clear lines of delegation, responsibility and accountability were being established throughout the staff team. These improvements needed to be sustained for the rating of is the service well-led? and the overall rating of the service to alter from requires improvement to a rating of good.

Feedback had been previously given by relatives and staff regarding the issues arising from inconsistent management of the home. New managers had sought further feedback since being in post. They had taken this into consideration when making necessary changes to improve the service. A significant decision had been made by the provider to no longer admit people who had been assessed as requiring nursing care. This was so staff could ensure people’s needs were met. It was confirmed during the inspection that there was no one living at the home with nursing needs. A supportive approach was being taken by managers to help some staff adjust to the new ways of working. People spoken with [apart from one] told us the changes were making the home a better place to live in. All relatives spoken with told us they felt reassured by the new management arrangements and the changes managers were making.

People’s needs had been assessed before their admission to The Lakes Care Centre and subsequently. There were arrangements in place to keep people safe and to protect them from harm. For example, improvements had been made to how people’s medicines were managed and how people’s risks were assessed and managed. This had resulted in safer medicine administration practice and a subsequent reduction in medicine errors. It had also resulted in risks to people being correctly assessed and managed. People were protected

Inspection areas



Updated 17 April 2018

The service was safe.

People received support to take their medicines safely and as prescribed.

Risks to people�s health and their safety were identified and actions taken to reduce these.

There were enough staff to ensure people�s needs were met. Safe staff recruitment processes helped to protect people from those who may not be suitable.

Actions were taken to protect people from potential abuse and discrimination.

People lived in a clean home where infection control measures were in place and where actions were taken to avoid potential risks.



Updated 17 April 2018

The service was effective.

Arrangements were in place to ensure staff completed necessary training. They were receiving the support they needed to professionally develop and for best practice to be established.

People�s needs were assessed on admission and thereafter to ensure they continued to receive the right level of support.

People were supported to make independent decisions. The principles of the Mental Capacity Act were adhered to and this protected those who lacked mental capacity.

People had access to health and social care professional as needed.

People�s nutritional wellbeing was supported and risks related to this identified and managed.

Adaptions had been made to the environment to meet people�s diverse needs.



Updated 17 April 2018

The service was caring.

People�s care was delivered with kindness and compassion.

Staff knew the people they cared for well and delivered their care around their preferences, likes, dislikes and diverse needs.

Relatives received support and were made to feel welcomed when they visited.

People�s dignity and privacy was maintained. Information held about people was kept secure and confidential.



Updated 17 April 2018

The service was responsive.

People and relatives had opportunities to be involved in planning the care which was delivered.

People were supported to take part in activities they enjoyed and which had a therapeutic value.

There were arrangements for complaints and areas of dissatisfaction to be raised, listened to and addressed.

People�s end of life wishes were explored with them in order to ensure these could be met at the appropriate time.


Requires improvement

Updated 17 April 2018

The service was well-led but the improvements made needed to be sustained and further developed.

People had benefited from there being strong and consistent leadership in place with values which supported their wellbeing.

Staff were being provided with support whilst positive changes to how the service ran were being made.

The provider�s quality monitoring arrangements helped to identify shortfalls and were now being used to make effective improvements.

People were supported to use the wider community but further links with community based groups were planned.