Lakeside 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.

At our last assessment we rated this key question Good. At this assessment the rating has changed to 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 the regulation relating to safe care and treatment.

This service scored 59 (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 based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

The provider maintained a record of falls and adverse incidents reported by staff within the service. An analysis was completed to identify patterns and trends so action could be taken to prevent events such as falls from recurring. However, it was not always evident this information was communicated to staff. Where there were other opportunities for learning and improvement, these were not always proactively addressed by the service management. For example, a number of medication errors had occurred before our assessment visit but had not been reviewed or addressed.

This contributed to a breach of the safe care and treatment and good governance regulations.

The provider worked well with people and healthcare partners to establish and maintain safe systems of care. However, they did not always manage or monitor people’s safety. They did not always make sure there was continuity of care when specialist advice had been shared.

Improvements were needed to ensure that where required, specialist guidance from healthcare professionals was accurately recorded within people’s care records to ensure identified risks were managed safely. There was a system in place to ensure smooth transition between services. For example, if people were transferred into emergency care there was a system for sharing information on people’s health conditions, medication and care needs.

This contributed to a breach of the safe care and treatment regulation.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There were systems to ensure people were protected from the risk of harm, abuse or discrimination. The service was currently working with the local authority safeguarding team in relation to a number of safeguarding concerns and the provider had shared relevant information.

Staff were able to clearly describe to us how they would identify potential abuse and what action they would take to escalate this appropriately. No concerns were raised by people or their relatives about the care and support they received from staff.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

The provider had systems and processes in place to monitor approved and pending DoLS applications.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Most people had individual care plans and risk assessments in place; however, these were not always reflective of immediate needs. Where people had specific health needs which placed them at risk of harm, risk assessments had been completed and the risks relating to the condition had been considered. However, risk assessments were not detailed or reflective of the care interventions people needed. For example, where people required support with a urinary catheter, care records did not evidence people had been involved in developing plans of care and decisions about how risk could be managed. We could not be assured people at risk of or recovering from pressure ulcers had been repositioned in-line with their assessed needs.

This contributed to a breach of the safe care and treatment regulation.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider undertook regular audits to monitor the safety of the home environment and equipment. Mobility, fire equipment and emergency lighting were tested regularly to ensure it was in good working order. There were also water temperature checks, legionella testing, gas safety certificates, electrical hard wiring and portable electrical appliance tests. We identified window restrictors within a newly built area of the service may not be fully compliant with published Health and Safety Executive guidance. We identified this to the provider for them to take appropriate action.

People had individual Personal Emergency Evacuation Plans (PEEPs) to aid them in being safely evacuated from the service in the event of an emergency, however we found some care plans contained conflicting information about people’s ability to move in the event of an evacuation. We communicated this to the service management. The provider had a continuity plan in the event of an evacuation being required or the loss of essential supplies such as electricity or water.

The provider had ensured there were enough qualified, skilled and experienced staff. They ensured staff received effective support, supervision and development. However, improvements were required around the oversight of staff training

The provider had training provision in place for staff, and no concerns were raised by staff in relation to the training and support provided. However, it was not evident there was sufficient provider or management level oversight to ensure staff had completed their training. Since July 2022, there has been a legal requirement for all staff to receive training in relation to supporting people with a learning disability and autistic people. The service management told us they were aware of this legal requirement and that training in this subject was provided, but staff had not completed it. This did not demonstrate effective monitoring or oversight.

Staff received supervision and appraisal to support them and develop them in their role. Staff were recruited safely with appropriate checks taking place to ensure their eligibility to work and suitability to work with vulnerable adults.

The provider had ensured there were sufficient staff on duty to meet the needs of people at the service. No significant concerns were raised by people, their relatives or staff about the number of staff on duty to support people.

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.

During our assessment visit, we observed the environment was clean and well maintained. Staff were seen wearing appropriate personal protective equipment when required and used it correctly, demonstrating good awareness of infection prevention and control practices.

No concerns were raised by people’s relatives or healthcare professionals in relation to the cleanliness of the environment. The registered manager and provider used auditing systems and processes to monitor the cleanliness of the service.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Two medicines administration recording systems were in use, paper medicines administration records (MAR) and electronic records. Staff were expected to record administration on both systems. However, we found gaps in both sets of records and inconsistencies between paper and electronic records. This meant we could not be assured people always received their medicines as prescribed.

We found when changes were made to people’s medicines, associated medicines records were not always updated in a timely way. This meant medicines were not always being given in accordance with the current MARs or dispensing instructions. Therefore, we could not be assured that people consistently received their medicines as prescribed.

Person-centred guidance for the administration of ‘when required’ (PRN) medicines was not always available to staff. This meant they did not always have clear guidance on when these medicines should be administered for each person. Therefore, we could not be assured PRNs were administered consistently in line with the prescriber’s directions.

We found several eye preparations with no date of opening recorded, or which had passed their ‘in-use’ expiry periods. Therefore, the provider could not be assured these medicines remained safe or effective for use.

Risks associated with the use of paraffin-based (flammable) products had not always been assessed or recorded. This meant appropriate measures were not in place to reduce the risk of harm to people.

Medicines related errors were reported, and immediate action was taken when required. However, leadership oversight was not always timely or effective in identifying trends and recurring issues. This increased the risk of repeated errors.

Staff received updated training in safe medicines management, and staff had competency assessments to show they gave medicines safely. However, there was no system to review and update competency assessments on an ongoing basis.

Medicines policies to guide staff were not always being followed. Some medicines audits were being completed. However, they had not identified the concerns found during this assessment.

This contributed to a breach of the safe care and treatment and good governance regulations.