CQC report explained · a nursing home
What the CQC found at Lakeshore Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention and control, including PPE, testing, social distancing, admissions, cleaning and outbreak management.
- Effective?
- Good
- This targeted inspection did not assess the effective key question.
- Caring?
- Good
- This targeted inspection did not assess the caring key question.
- Responsive?
- Good
- This targeted inspection did not assess the responsive key question.
- Well-led?
- Good
- This targeted inspection did not assess the well-led key question.
What inspectors found, March 2021
St David's Nursing Home: Inspected but not rated; inspectors were assured about infection prevention and COVID-19 safety measures.
This was an announced, targeted inspection on 24 February 2021. It looked at infection prevention and control during the coronavirus pandemic, rather than the full quality of care.
Inspectors were assured that the home was managing visitors, social distancing, admissions, PPE, testing, cleaning and possible outbreaks. They also found COVID-19 risks had been assessed for people and staff.
People could keep in touch with relatives through visits, telephone and video calls. The home had a visiting marquee, window visits, communal areas, garden access and socially distanced activities.
The service was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating for the overall service.
COVID-19 risk planning
Individual COVID-19 risks for people and staff had been assessed, with plans setting out extra precautions.
“People's individual risks in relation to COVID-19 had been completed and plans were in place to detail the extra precautions staff should take to minimise the risk of infection.” from the report
Keeping families connected
The home supported visits and contact by telephone, video calls and window visits. A marquee gave families a dedicated visiting space.
“People were supported to have visitors. There was a large marquee joined onto the activity lounge and there were glass doors separating the two areas.” from the report
PPE and infection controls
Inspectors saw staff using the correct PPE, with PPE stations available throughout the home.
“Staff were observed to be wearing the correct Personal Protective Equipment (PPE) and there were PPE stations throughout the home.” from the report
Inspectors raised no specific concerns in this report.
- 01How do your current visiting arrangements compare with those described in the report?
- 02How are individual infection risks and staff health risks assessed now?
- 03How often are people living here and staff tested for COVID-19, and what happens after a positive result?
- 04How would you isolate someone who tests positive or returns from hospital?
- 05Can you show us the latest ratings or inspection information for effective, caring, responsive and well-led care?
This was a targeted inspection of infection prevention and control under the Safe question; the service was inspected but not rated and the other four questions were not assessed. This explanation was written from the published report of 17 March 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.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind care, but some best-interest decisions were not documented clearly.
This was an unannounced inspection on 11 February 2020. Two inspectors spoke with five people living in the home, two relatives and staff. They reviewed care and medicines records, recruitment, training and quality checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, clean surroundings and good support from healthcare professionals.
The home was asked to improve how it records decisions made for people who cannot make some decisions for themselves. Some care records were also difficult to follow and had not been fully rewritten after changes in people's needs.
Enough staff
People and relatives said staff were available, and inspectors saw enough staff across the home.
“People we spoke with told us there were consistently enough staff.” from the report
Safe medicines
Medicine records showed medicines were given as prescribed, with no gaps found. Stock and storage checks were also satisfactory.
“A review of people's Medicine Administration Record charts showed people were given their medicines as prescribed.” from the report
Kind and respectful care
Inspectors saw staff taking time with people and supporting them in a gentle and respectful way.
“Our observations showed staff treated people in a kind way and took their time when supporting people.” from the report
Activities and visitors
People could see visitors without restriction and were supported with activities, interests and religious practice.
“There was an activities coordinator employed who organised group activities and spent time individually with people.” from the report
Open management
People and staff described the home as well run. The manager was visible and approachable.
“The registered manager was a visible presence in the home.” from the report
Best-interest decisions not always recorded
needs fixingDecisions about care and treatment were not consistently documented or linked to the specific decision. This included covert medicines and bedrails.
“Best interest decisions made about people's care and treatment were not consistently documented.” from the report
Some care records were hard to follow
needs fixingSome care plans and risk assessments had not been rewritten for several years. Important changes were sometimes added elsewhere in the record or handwritten onto the original document.
“People's care records contained a lot of information and were sometimes difficult to navigate.” from the report
Some staff needed a better understanding of the law
needs fixingNot all staff understood the rules about mental capacity and best-interest decisions well enough.
“Not all of the staff we spoke with had a good understanding of the MCA and best interest decisions.” from the report
- 01How do you make sure every best-interest decision is recorded for the specific decision involved?
- 02How are decisions about covert medicines and bedrails reviewed and documented?
- 03Have all staff completed further training on mental capacity and best-interest decisions?
- 04How has the electronic care-record system improved the updating and checking of care plans?
- 05How do you record and respect a person's end-of-life wishes if they do want to discuss them?
This was an unannounced planned inspection covering all five CQC questions and the overall rating. This explanation was written from the published report of 12 March 2020 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 Lakeshore Nursing Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- March 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.