CQC report explained · a nursing home
What the CQC found at Lakeside Nursing & Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from harm and medicines were managed safely. Care plans and risk assessments were detailed, although some staff raised concerns about staffing during busy periods.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Management systems, audits and record keeping had improved. Staff felt supported and inspectors found a positive culture, although the system for recording prescribed creams was not best practice.
What inspectors found, September 2021
Lakeside Nursing & Residential Home is rated Good; inspectors found safe, well-managed care, but staffing levels and cream records needed review.
This was a focused inspection on 9 and 28 July 2021. Inspectors looked mainly at safety and how the home was managed. They spoke with people, relatives and staff, and checked care, medicine, staff and management records.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found people were protected from harm, medicines were managed safely, care plans were detailed and infection control arrangements were suitable.
Some staff said there were not enough staff during busy periods, so inspectors recommended a review of staffing structures. The home also used two systems to record prescribed creams, which inspectors said was not best practice.
The previous overall rating was Requires Improvement in December 2019. The provider had improved its records and quality checks, and was no longer in breach of Regulation 17 at this inspection.
People felt safe
People and relatives told inspectors they trusted staff and felt safe. Staff had safeguarding training and understood how to report concerns.
“People were protected from the risk of harm and people said they trusted staff to keep them safe.” from the report
Safe medicines practice
People received their medicines on time and staff were trained and checked as competent before administering them.
“Medicines were managed safely. People received their medicines in a safe way and systems ensured timely administration of medicines.” from the report
Detailed risk planning
Care plans and risk assessments reflected people's individual needs. Pressure care, falls risks and moving equipment were being managed.
“Care plans were detailed and included risk assessments in relation to people's specific care needs.” from the report
Improved management
Audits and record keeping had improved since the previous inspection. The provider was no longer in breach of the governance regulation.
“Robust auditing systems were in place which comprised of various manager and provider level audits.” from the report
Positive culture
People said they were happy and their choices were respected. Staff, people and relatives were asked for their views through meetings, surveys and regular contact.
“There was a good culture within the service which had a positive impact on people.” from the report
Staffing at busy times
needs fixingInspectors saw suitable staffing levels during the visit, but some staff said they needed more staff during busy periods. Inspectors recommended that staffing structures were reviewed.
“We recommend the provider reviews their staffing structures.” from the report
Two records for prescribed creams
minorPrescribed creams were being recorded consistently, but nursing and care staff used separate recording systems. Inspectors said this was not best practice and recommended a review.
“However, the provider had two systems in place to record the administration of prescribed creams which was not best practice.” from the report
- 01How many staff are normally available during the busiest parts of the day?
- 02What has changed in the staffing structure since inspectors recommended a review?
- 03How are prescribed creams now recorded, and is there one clear system for all staff?
- 04Which current ratings came from the previous comprehensive inspection rather than this focused visit?
- 05How are people and relatives told about improvements made since the Requires Improvement rating?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 3 September 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, December 2019
Rated Requires Improvement; inspectors found good care in most areas, but leadership and record keeping were not reliable enough.
This was an unannounced inspection over 19 and 20 August 2019. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, staff and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People told inspectors they felt safe, staff were kind, care was personalised, meals were good and activities supported people's interests.
The overall rating was Requires Improvement because Well-led had fallen from Good to Requires Improvement. Inspectors found incomplete records, care records that were not stored securely, and weak monitoring of call bell response times.
The home breached Regulation 17 on good governance. The provider was asked for an action plan, and CQC said it would monitor progress and return under its re-inspection programme.
Kind and respectful staff
People described staff as kind, gentle and respectful. Inspectors observed staff supporting people with compassion and dignity.
“The carers are extremely nice and caring.” from the report
People felt safe
People told inspectors they trusted staff to keep them safe. Staff had safeguarding training and understood how to raise concerns.
“People were protected from the risks of abuse and harm and people said they trusted staff to keep them safe.” from the report
Personalised care
Care plans included people's needs, wishes, cultural and religious preferences, and life histories. People and relatives were involved in reviews.
“Holistic assessments and care plans had been completed which reflected people's needs, wishes and preferences.” from the report
Food and activities
People had meal choices, support with eating and drinking, and access to snacks and drinks. Activities were varied and linked to people's interests.
“We found people had a say in the type of activities and trips planned, and observed people engaging and enjoying the activities they took part in.” from the report
Incomplete treatment records
seriousAll 12 topical cream charts reviewed had gaps in signing. This meant the home could not reliably show that treatments had been recorded each time.
“during the inspection we noted sufficient action had not been taken as records remained incomplete for all 12 people's topical cream charts that were reviewed.” from the report
Records not securely stored
seriousCare records were kept in an unlocked cupboard in the communal dining room, where unauthorised people could access them. The cupboard was locked during the inspection.
“The cupboard was unsecure which meant care records could be easily accessed by unauthorised people.” from the report
Confidentiality risk in meetings
needs fixingDaily staff meetings took place in the communal dining room. Inspectors said people or visitors could overhear confidential information.
“This meant there could be a risk of people's confidential information being overheard.” from the report
Call bell monitoring
needs fixingSome people said they waited for help after pressing their call bell. The manager could not provide an average response time because monitoring systems were not robust.
“A couple of people told us they had to wait for support when they had pressed their call bell.” from the report
Moving equipment storage
needs fixingHoists, stand aids and walking frames were stored in communal bathrooms. Inspectors recommended following appropriate guidance because this could pose a health and safety risk.
“It is a risk for moving and handling equipment to be stored in communal areas as they pose a risk to people's health and safety.” from the report
- 01How have you made sure topical cream charts are now signed fully and accurately?
- 02Where are care records stored now, and how do you prevent unauthorised access?
- 03How do you monitor and review call bell response times, and what were the latest results?
- 04Where are moving and handling aids stored, and what action has been taken about the communal bathrooms?
- 05How are daily air-flow mattress checks and pressure-care records now documented?
This was an unannounced inspection covering all five CQC questions; the previous overall rating was Good, but Well-led fell to Requires Improvement. This explanation was written from the published report of 14 December 2019 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 Lakeside Nursing & Residential Home
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- September 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Lakeside Nursing & Residential Home →
- December 2019Requires improvementdown from GoodSafe: GoodWell-led: Requires improvement
Read what inspectors found at Lakeside Nursing & Residential Home →
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Good
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 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.
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