Lakeside Care Home

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.

At our last assessment, we rated this key question Good. At this assessment, the rating has changed to Requires Improvement.

This meant the management and leadership was inconsistent. Leaders did not always ensure the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

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 provider was keen for staff to feel involved in and take pride in the service. The provider was actively involved in the day-to-day running of the service. There was a positive culture at the service, and staff felt positive about their employment.

Staff felt supported by the service management team to deliver consistently safe, person-centred and inclusive care. All the feedback we received from staff about the culture of the service was positive. One staff member said, “We are definitely supported by management. They are very approachable, and there is good team morale.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not consistently have the skills, knowledge, experience and credibility to lead effectively.

It was evident the provider and service management were clearly committed and passionate about ensuring everybody living at the service had a high quality of life and good experience. We received positive feedback about the service management from people, relatives and staff. However, we identified there were areas of improvement required around individual roles and capabilities to ensure the requirements of the regulations were met. There was no provider level oversight to ensure the service management was fulfilling the requirements of their role. This had resulted in a breakdown of governance arrangements.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and staff told us the provider and service management were approachable, and they felt confident to raise any concerns and felt action would be taken to resolve concerns.People spoke positively of the provider and service management, with one comment being, “You often see the manager. The owner is here regularly too. He’s very friendly and will chat.” There were opportunities for staff to raise concerns in supervision. Whilst staff did not raise any concerns, formal joint staff meetings had been undertaken since February 2026. A formal approach to staff meetings would ensure staff were encouraged to share ideas, raise concerns and provide positive feedback amongst their colleagues.

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.

Staff were treated fairly, with leaders taking a flexible and supportive approach that recognised individual needs and circumstances. Staff all received the same opportunities to train and develop themselves. The provider and registered manager told us staff were encouraged to contribute to the service development through regular supervisions.Staff said they felt valued and supported in their roles and no concerns were raised around equality and inclusion. Staff received training opportunities on communicating effectively and diversity and equality, however the training record evidenced staff completion rates were very low. This training was to support staff to understand and uphold inclusive practices in both care delivery and team interactions.

The provider did not 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.

Systems operated by the provider and registered manager were not robust enough to assess, monitor and improve the quality and safety of the service and ensure regulations were met. There was a lack of formal provider oversight, which had resulted in a failure to identify concerns about the inadequate governance arrangements. Although the provider was regularly at the service, there was no formally recorded process to ensure other members of the service management team were fulfilling the requirements of their roles.

During our assessment, we identified people were at risk of unsafe or inappropriate care and treatment due to ineffective governance and oversight. There were insufficient systems and processes to ensure medicines management was safe, records relating to bowel monitoring, fluid consumption and repositioning were accurately completed, and the Mental Capacity Act 2005 was complied with. There was no effective system to audit care records, which had resulted in unclear and conflicting information. There was no effective oversight of staff training completion, which had led to low staff training uptake and legally required training not being completed by all staff.

This contributed to a continued breach of regulation in relation to good governance.

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 provider was currently working in partnership with the local authority to investigate where safeguarding concerns had been raised.The service worked with local GP surgeries and other healthcare services where required. We did not receive any feedback from external healthcare professionals to support our findings during this assessment process.

People at the service had opportunities to visit local facilities as part of the organised activity programme. People were also supported to have group lunches at local venues.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider did not have an effective system or plan to monitor and improve the quality and safety of the service. The service management told us the service did not have a Service Improvement Plan (SIP). There were no formal quality monitoring systems that could form part of a SIP to record and make improvements to people’s quality of care.

Governance records showed audits and checks had not been completed effectively and lessons learned were not always demonstrated through service-wide improvement activity. Following the assessment, the service management informed us of the improvements they planned to make in relation to governance and oversight as a result of the findings.