CQC report explained · a residential care home
What the CQC found at Lakenham Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found appropriate staffing, safer recruitment checks, individual risk assessments, safe medicines management and infection control arrangements. People said they felt safe with staff.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found regular audits, action taken when improvements were needed, open communication and a stronger focus on person-centred care.
What inspectors found, November 2022
Rated Good; inspectors found safe, kind care and improvements since the previous inspection, but there was no registered manager in post.
This was an unannounced focused inspection on 26 October 2022. One inspector spoke with five people, seven staff members, two relatives and one health and social care professional. They also reviewed care records, staff recruitment files and quality checks.
Inspectors rated Safe and Well-led as Good. They found suitable staffing, safer recruitment checks, reviewed risk assessments, safe medicines practice and infection control measures. People said they felt safe and described staff as kind and compassionate.
The home had improved since the previous inspection, which was rated Requires Improvement and found breaches of regulations. At this inspection, those breaches had been addressed and the home was no longer in breach. The overall Good rating also used ratings from the previous inspection for the other areas, which were not inspected this time.
Staffing and recruitment
Staff were deployed to meet people's needs in a timely way. Recruitment included interviews, references and Disclosure and Barring Service checks.
“There were effective recruitment and selection processes in place.” from the report
People felt safe
People appeared comfortable with staff and staff understood how to recognise and report abuse.
“I feel really safe here, the staff look after me. I have no concerns.” from the report
Safe medicines
Medicines were checked on arrival, recorded when given and reviewed through audits. Staff had medicine training.
“People's medicines were managed so they received them safely.” from the report
Learning and oversight
The home had regular checks covering care plans, risks, medicines, incidents and safety. Actions were followed up when needed.
“Systems were in place to monitor the quality and safety of the service.” from the report
Kind and personalised care
People and relatives described staff as kind and supportive. The home was developing life stories and a dementia care programme to make support more personal.
“The service sought feedback from people who use the service to identify areas for improvement.” from the report
No registered manager in post
minorThere was a new manager in post, but they had not yet registered with the CQC at the time of the inspection. The manager said they intended to apply.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Has the new manager applied to register with the CQC, and what is the current position?
- 02How do you keep risk assessments, comfort charts and handover information up to date?
- 03How are medicines checked to make sure they are given as prescribed and records are complete?
- 04How will you make sure the improvements in person-centred care continue?
- 05What was the previous rating for Effective, Caring and Responsive, and when will these areas next be reviewed?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 17 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2021
Rated Requires Improvement; inspectors found kind care but gaps in person-centred care, safety checks and quality oversight.
This was a focused inspection on 19 and 25 August 2021. Inspectors looked at Safe and Well-led only. They observed care, spoke with people, staff and others, checked records, medicines, recruitment and infection control.
Some people waited up to 45 minutes for lunch while staff were caring for residents in bedrooms during an infection outbreak. Inspectors also found one person without a call bell and were unsure when they had last been checked, had a drink or eaten. Mattress checks and controlled medicine records were also not always completed properly.
The home acted quickly when these issues were raised. It ordered warming plates, introduced comfort charts and added individual weight charts for mattress settings. However, its audits had not found these problems. The overall rating changed from Good at the 2017 inspection to Requires Improvement.
Kind and caring staff
People said they felt safe and described staff as kind and caring.
“The staff are so caring and kind.” from the report
Risks were usually assessed
Care plans included information about people's risks and how to reduce them. Health and social care professionals were involved when people's needs changed.
“Where risks were identified, there was guidance in place to reduce the risk of harm.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including use of protective equipment and facilitating visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Learning from incidents
Inspectors found examples of care plans and risk assessments being updated when people's health needs changed.
“There was evidence that learning from incidents and investigations took place and appropriate changes were implemented.” from the report
Activities and communication
People could take part in regular activities. Staff said they could raise concerns, and complaints were recorded and answered within appropriate times.
“Despite the challenges of staffing, people were able to engage in a range of activities.” from the report
Cold and delayed meals
needs fixingSome people waited up to 45 minutes for lunch while meals were being delivered to bedrooms. Their food was cold and unappetising.
“some people were waiting for their lunch for up to 45 minutes, which resulted in their food being cold and unappetising.” from the report
A person was not checked clearly
seriousInspectors found one person alone in a bedroom without a call bell. They could not establish when the person had last been checked, had a drink or eaten.
“The door was closed, and they had no call bell so could not be heard if needed assistance.” from the report
Controlled drug records
seriousThere were four occasions when controlled drug records had only one signature instead of two. Existing audits had not identified this.
“There were four occasions when this had happened, with only one staff member signing.” from the report
Quality checks missed problems
seriousThe home's audits did not identify the concerns found during the inspection. This led to a breach of the good governance regulation and placed people at risk.
“systems were either not in place or robust enough to demonstrate safety was effectively managed.” from the report
Recruitment records
minorThe home carried out appropriate recruitment checks, but did not record discussions about gaps in applicants' employment histories.
“despite interviews and discussions taking place regarding any gaps in employment history, these were not documented.” from the report
- 01What staffing arrangements are now in place when people need to be cared for in their bedrooms?
- 02How do you make sure every person has a working call bell and is checked regularly, with drinks and food available?
- 03What changes have been made to controlled drug signing and the auditing of medicines?
- 04How are mattress settings checked against each person's weight and recorded?
- 05What actions were included in the improvement plan, and what evidence can you show that they have been completed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 21 October 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lakenham Residential Care Home
7 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Lakenham Residential Care Home →
- October 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Lakenham Residential Care Home →
- February 2021Inspected but not ratedSafe: Inspected but not rated
- October 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- September 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2016Requires improvementstayed Requires improvementSafe: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 25 January 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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