Lakeview

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider ensured there was an electronic system in place which contained details of the accidents and incidents which had occurred. Incidents were recorded promptly with clear details of the event, actions taken and any follow up required.

The registered manager ensured incidents and complaints were investigated appropriately, with outcomes and lessons shared with staff to reduce the risk of recurrence. The last 3 concerns raised were managed in a timely manner and resolutions were identified and actioned.

The provider monitored the themes and trends of safety events which identified areas for improvement. There was evidence of openness and transparency, in line with duty of candour requirements.

Staff knew what accidents and incidents were and were aware of the reporting process.

The provider ensured staff learned lessons from safety events. There were various ways in which learning was communicated with staff including handovers, a huddle board and notes informing staff of learning could be inputted onto the electronic care planning system.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider ensured there were systems in place which ensured people experienced safe care when moving through different stages of their care pathway. Staff followed clear policies and procedures to support safe admission into the care home.

The provider ensured pre – admission assessments were completed for people to ensure they were suitable for the service, and the service was appropriate to meet their health and social care needs.

Staff shared relevant information promptly and appropriately with other providers to support safe transitions. We saw examples within care records of how staff had appropriately referred people to relevant services when required, this included the community mental health team. People had emergency information available which was shared with professionals when required.

The provider ensured there was effective multi – disciplinary working and communication with external agencies. The provider worked closely with other services including the community mental health team, the local hospice and doctors involved with people’s care.

People told us their experience of moving into the service was positive.

Staff told us they were made aware of new people moving into the service in advance of them doing so and felt the care plans and risk assessments were robust enough to give them a clear idea of the person.

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.

The provider had up to date policies and procedures in place to protect people from abuse and neglect. The registered manager was the safeguarding lead. Staff understood their roles and responsibilities in relation to safeguarding and could describe how they would identify and respond to concerns.

The provider had a Deprivation of Liberty Safeguard’s (DoLS) tracker which contained details of who had a DoLS in place, when a DoLS had been applied for, the authorisation status, the representatives involved and whether there were conditions or requirements on the DoLS which had been granted.

The registered manager ensured staff were trained in safeguarding. Training records showed staff had completed safeguarding training at a level appropriate to their role, and there were systems to monitor when refresher training was due.

The registered manager ensured safeguarding concerns were recorded and escalated in line with local authority procedures. We reviewed the referrals which had been made to the CQC, in line with the equivalent level of referral which had been sent to the local authority and found these matched up.

Staff were aware of what to look out for in relation to safeguarding concerns. They reported feeling confident in raising concerns and knew who the safeguarding lead was within the service.

People were provided with service user guides when they moved into the service which clearly outlined how to report any safeguarding concerns.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider ensured staff had access to policies which were specific to the diagnoses of the people being cared for. For example, staff had access to up-to-date policies for the management of diabetes, bariatric care, the management of dysphagia (difficulties swallowing) and tracheostomies (a tube which is inserted into a surgical opening in the front of the neck to allow people to breathe when their airway is blocked, narrowed, or other wised compromised).

Staff ensured risk assessments were carried out in partnership with residents and, where appropriate, their families or advocates. Staff encouraged people to express their views and involved them in regular reviews of their care plan.

Staff ensured care plans reflected people’s choices, preferences, and consent, and demonstrated how risks were balanced with maintaining independence and quality of life. We observed positive behaviour support sections of care plans which were detailed and provided strategies for staff to follow which were in line with the least restrictive intervention used.

People, relatives or professionals provided information about the person, and this was used to ensure activities and care was safe and person centred. For example, a person had a fear of water and so activities were adapted for them to ensure this was avoided.

Staff recorded behaviours of concern on an electronic system and used antecedent, behaviours and consequences (ABC) charts which help staff, leaders and potentially other professionals understand the triggers, actions and consequences of interventions. The registered manager had oversight of the ABC charts and completed regular reviews of this information. The provider also ensured staff had access to a behaviour support team who were qualified Positive Behaviour Support (PBS) colleagues.

Residents told us they felt listened to and supported to make decisions about their daily lives, including taking positive risks such as engaging in community activities or pursuing hobbies.

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 ensured safety checks were completed, and certification was in place which confirmed utilities and equipment were safe to use; detailed records were kept of all equipment certificates and utilities supplies. Portable appliance testing was up to date and equipment was serviced as required. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Regular fire safety checks and fire drills were completed. A fire risk assessment had been completed.

The provider ensured people’s care plans regarding the environment and equipment was in place. These were person centred and clearly outlined the types of equipment, the risks involved and how staff should mitigate such risks. Furthermore, general risk assessments for the home had been completed for 2025.

People were cared for in safe environments that were designed to meet their needs. The care home had 3 units; all located on different floors. Males and females were separated by the floor they were located on. Each floor contained a dining room area, a living area and large bedrooms with wide doors which ensured they were accessible by wheelchairs. The corridors had laminate flooring and handrails on either side. Dementia-friendly signage was observed throughout, as well as a tactile board on the first floor. The home was well lit, stairwells contained fire evacuation equipment and there were 2 large elevators which supported the weight of 16 people so were appropriate for wheelchairs. The service also had a communal area on the ground floor which was primarily for activities. Next to the communal area was a kitchen area which was used for supporting people to develop their independence skills including cooking food. The service had a terrace area and a garden area at the back of the property which they were redeveloping and would include a sensory area and would be more accessible for the people residing at the care home.

The provider completed a range of environmental audits regularly throughout the year. We saw evidence of a building, maintenance and housekeeping audit, a hazardous substance audit, a workplace equipment audit and a servicing and certification audit, all which were scored above 90% for compliance.

Staff used equipment to deliver care and treatment which was suitable for the intended purpose. We found equipment to be in good working order and used properly. When it was not in use it was stored securely.

Staff, people and relatives did not raise any concerns regarding the environment or equipment within the home and confirmed that fire evacuation drills were completed regularly.

We did identify the doors to access the Bridgewater unit, which should have been lockable were not and 2 of the fridges within the medication rooms had faulty locks. We raised this with the registered manager who was aware and provided evidence this had been raised with maintenance and since then an external company who were due to fix them.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider ensured staffing levels were safe, effective and responsive to people’s individual needs. Staffing rotas were planned and regularly reviewed to ensure there were always enough suitably skilled staff on duty. Staffing numbers were adjusted according to people’s dependency levels.

The provider ensured there were processes in place to cover unplanned absences, including access to agency staff, although the service prioritised continuity of care by ensuring familiar staff were used where possible.

Staff reported staffing levels were sufficient and allowed them to provide safe, person centred care without rushing tasks.

The provider ensured there were robust and safe recruitment practices to make sure that all staff, were suitably experienced, competent and able to carry out their role. Leaders recruited staff safely, with all necessary checks and documentation in place. Application forms were fully completed, and at least 2 references were obtained prior to a starting work. Interview questions and answers forms were kept. UK disclosure and barring service (DBS) checks were completed to ensure staff were of suitable character to work with vulnerable adults.

Staff had the right mix of skills, experience and qualifications to meet people’s needs. New staff completed a structured induction programme, and ongoing training ensured skills remained up to date. A member of staff who was currently on their induction told us “The induction is great; it’s the best I have ever had.”

Staff had an overall mandatory training compliance rate of 95% which was monitored closely by leaders. Staff also completed additional training courses, which included person centred support and approaches, bed rails, customer care and communication and asbestos training. However, a specialist service told us they felt staff needed to engage with them closer to ensure specialist training was up to date.

The registered manager ensured staff had access to regular supervision and appraisals.

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.

The units were clean and tidy with no malodours. Equipment was cleaned and stored appropriately to avoid cross infection. Floors were mopped and handrails clean. The communal area on the ground floor where people engaged in activities and the communal kitchen required the high areas to be cleaned as we noticed dust and spider’s webs. We raised this with the registered manager as part of the feedback, and they explained this would be resolved by the following day.

The provider had clear policies and procedures in place to prevent and control the spread of infection.

Staff had completed mandatory training in infection prevention and control, and their competency was monitored through observations and audits. Staff demonstrated good knowledge of hand hygiene, use of personal protective equipment (PPE), and the importance of maintaining a clean and safe environment.

The provider had robust systems in place to manage outbreaks of infectious illness, including clear contingency plans, isolation procedures, and liaison with external health professionals such as the local infection prevention and control (IPC) team.

The provider ensured regular audits were completed on hand hygiene, environmental cleanliness, and the use of PPE, with findings acted upon promptly to maintain safe standards. The last 3 IPC audits from July, August and September 2025 showed a compliance rate of 97% and above.

People we spoke with and almost all staff raised no concerns regarding the cleanliness of the home or IPC practices.

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 document when patch applications were applied, and patches were not being rotated around different sites of people’s bodies in line with manufacturer’s guidance. The provider’s policy did not contain specific details about how frequently a patch should be applied to the same site.

People, whose medication was prescribed on a when required basis, had protocols in place. However, some of the information, included in some of the protocols was not sufficient to inform the staff of how and when it was appropriate to administer these medicines.

The provider ensured staff had information available to them regarding how to prepare medications for people whose medication was administered directly into their stomach via a tube. However, this information had not been consolidated into a robust written protocol to inform staff on how to prepare and administer these medicines safely and consistently.

Staff were not always measuring and recording the maximum and minimum refrigerator temperatures and therefore were not able to demonstrate medicines were consistently being stored at a temperature between 2°C and 8°C.

Processes were in place for the timely ordering and supply of medicines. Some people were involved in the ordering or their medication.

Medicine administration records (MARs) were being used to record the administration of medicines and showed people were given their medicines at the right time. An accurate record was made when medicines were not administered, for example, when medicines were refused.

When people were refusing their medicines, their mental capacity was assessed, recorded and they were supported appropriately. To maintain people’s health and wellbeing these people were having their medicines administered by disguising them in either food or drink, this is known as covert administration.

Controlled Drugs records recorded the receipt, administration and disposal of Controlled Drugs and were audited on a regular basis.

Staff were trained and were assessed as competent to administer medicines safely.

People’s allergies were accurately recorded.