Lakeside Residential 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 requires improvement. At this assessment, the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to management and governance at the service.

This service scored 54 (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 have a clear shared vision, strategy and culture which was based on transparency, inclusion, and engagement.

The registered manager had implemented forms for incidents and accidents and told us that they wanted to introduce a culture of accountability with staff at the service. However, minutes from huddles held did not evidence improvements and learning within the team. One staff member told us "The changes which have been made by the manager are hit or miss. There are so many forms to fill out we sometimes don’t get chance to get them done."

The service improvement plan was insufficient and did not always provide details on the progress or outcome of identified actions. Additionally, the plan did not include information on the impact or involvement of staff and people using the service and we were not assured about the effectiveness of the audit process.

Equality and diversity policies were in place and in-line with current best practice guidance. However, completion of training in this area was low.

Leaders did not always embody the culture and values of their workforce and organisation. Leaders did not always lead with integrity, openness, and honesty.

The registered manager told us they had been working at a different service due to issues it was experiencing and, as such, was not a visible presence within Lakeside or able to lead by example. Following our assessment, we were informed there was to be a further change in management. Stable and consistent management is required to support and drive improvement within a service, as well as improve morale in the team.

We were not assured the provider had identified staff with the aim of developing them into future leaders. One staff member told us they had been discouraged from pursuing care qualifications.

People did not always feel they could speak up and that their voice would be heard.

Staff told us that they felt they could speak up if they needed to, however, one staff member told us, "The manager says there is an open-door policy but is often busy and says come back later."

Records of the most recent team meetings did not include details regarding staff concerns, including incidents and accidents. The records did not state whether any opportunity had been given to staff to speak up or of their involvement in the meeting.

Whilst the provider had a confidential reporting policy, one member of staff told us they were not aware of it and had not been told about the whistleblowing procedure.

Some of the people and relatives we spoke with were not aware who the manager was or said they were not always available within the home. However, said they felt able to speak with staff if they had any concerns. was We received mixed feedback from staff and people using the service. People told us, “If I have a problem, I know that they will listen to it” and “If you catch [manager] when she's not too busy she is okay."

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was insufficient evidence of the provider actively reviewing and improving organisational culture. The provider had not followed their own policy in ensuring staff were suitably trained in understanding equality and diversity.

We were not assured the provider had taken action to reduce disparities in the workforce. We received mixed feedback from staff regarding the provider's communication and inclusion of staff in decision-making processes. Staff also told us about low morale due to a lack of transparency around management decisions.

However, the registered manager told us of some reasonable adjustments made to staff working arrangements to support staff and help them succeed in their roles.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance, and outcomes, or share this securely with others when appropriate.

Management and oversight of the service had not been effective. The manager was newly registered, however, was not visible at the service due to working at a different site and, as such, some of the people and relatives we spoke with were not aware who was managing the home.

Whilst systems were being implemented, they had not been embedded to evidence on-going improvements. The provider's improvement plan focused on the environment and lacked details on other key areas of improvement such as training and development and engagement with people who use the service.

Audits and checks were not sufficiently robust and did not provide evidence actions identified had been acted on. Lessons learned huddles did not always show staff had attended and were unclear how learning was shared with the whole team. Staff were not supported effectively to maintain high standards of care. The provider’s supervision records showed staff supervisions were not held regularly, falling short of recommended standards.

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 registered manager had expanded on the pre-admissions assessment process so that people and those important to them were actively involved in identifying and planning their care prior to moving into the service.

We were told that, within the past year, people had been offered opportunities to join in with local groups, including a local school for cake bakes and brass band events at the service. During the recent Victory in Europe Day celebrations some people also attended a boat trip around the nearby lake.

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.

Some quality assurance systems were in place to support the analysis of events and capture lessons learnt. However, there was no evidence to support lessons learnt had resulted in changes to practice, improved staff training and updated policies and procedures.

Staff had not received the necessary training on the computer-based care system before it was implemented, meaning they were unsure how to use it. In addition, staff did not have easy access to computers, as only two were available.

The manager had installed a compliments board in the main reception area where people were encouraged to record compliments to acknowledge the good work done by staff. One comment, made in March 2025, requested more activities for people using the service. The provider had responded to say that a new monthly activities planner had been displayed, and they would try to introduce more activities. However, at the time of assessment the provider did not have a dedicated activities coordinator.