During an assessment under our new approach
Date of assessment: 9 September 2026 to 30 September 2026. The assessment was prompted due to concerns raised with us about unsafe care being provided.
Lakeside Care Home is registered to provide personal care for up to 40 people. At the time of our assessment, 36 people were living at the service.
We found 3 breaches of the regulations in relation to consent, safe care and treatment and governance.
People’s care plans were not always sufficiently detailed to ensure staff had all the information they required to safely meet their needs, and some contained contradictory information. This meant people were at risk of not receiving the care they required to keep them safe. We identified an example where this had adversely affected the quality of life of 1 person. Records did not evidence that people consistently received safe care and treatment, or that risks were identified and managed in a timely or effective way. Medicines were not managed safely, which placed people at risk.
People’s rights under The Mental Capacity Act 2005 were not fully upheld. The absence of effective monitoring and provider level oversight meant mental capacity assessments or best interest decisions were not in place where the provider was undertaking restrictive practices. Whilst this had not significantly impacted people, it did not evidence compliance with the relevant regulations.
Leadership and governance were not effective. There was limited provider and service management level oversight. The absence of effective provider level oversight had not ensured the service management had performed their roles effectively to meet the requirements of the regulations. Provider level systems to monitor quality and drive improvement were not robust.
Although the provider was regularly in the service, recorded governance was not undertaken and there were no clear action plans produced by the provider to monitor progress or drive improvement. There were limited quality assurance processes in place to improve quality of life for people through a service improvement plan.
Staff felt supported in their roles and spoke of the service leadership being a significant positive factor in this. Although there was a staff training schedule, the absence of monitoring staff training completion by the service management had resulted in legally required training not being completed by all staff.
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