CQC report explained · a residential care home
What the CQC found at OSJCT Lake House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. There were enough staff, risks were assessed and managed, and medicines were stored and given safely.
- Effective?
- Good
- People's needs were assessed before they moved in. Staff had suitable skills and training, and people were supported with food, drinks, healthcare and decisions about their care.
- Caring?
- Good
- Staff were observed speaking respectfully and supporting people's privacy, dignity and independence. People were involved in decisions about their care.
- Responsive?
- Good
- Care plans included people's needs, preferences and communication methods, and relatives were involved in reviews. However, inspectors found that activities could be improved.
- Well-led?
- Good
- People, relatives and staff said the home was well run. Inspectors found open communication, effective teamwork and quality checks that were used to improve the service.
What inspectors found, November 2018
OSJCT Lake House was rated Good; inspectors found safe, kind and well-managed care, but activities needed to improve.
Inspectors visited the home without notice on 9 October 2018. They spoke with people, relatives, staff and health professionals. They checked care records, medicines records, staff files, the building and the home's quality checks.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safe medicines systems, suitable staff training and good support with food, healthcare and personal choices.
People were treated with dignity and respect. Staff understood people's needs and worked well as a team. The main shortfall was that activities were not always available or personal enough, and some people said they were bored.
The previous inspection in September 2017 rated the home Requires Improvement and found one breach. Inspectors found that improvements had been made, including to staff recruitment, and there were no breaches reported at this inspection.
Kind and respectful care
Staff were observed speaking politely and respectfully. They protected people's privacy and supported people to remain independent.
“Throughout our inspection, we observed many caring interactions between staff and the people they were supporting.” from the report
Good support with food and health
People could choose their food and drinks and received support where needed. Inspectors saw a relaxed, social meal and found that healthcare referrals were made promptly.
“This was an enjoyable, social event where most people attended.” from the report
Open management and improvement
Staff said managers were approachable and supportive. The home used meetings, feedback and quality checks to identify and make improvements.
“The leadership created a culture of openness that made people and staff feel included and well supported.” from the report
Activities were not consistent enough
needs fixingInspectors did not see formal activities on the inspection day because the activities coordinator was away. People gave mixed views, including that the home could be boring, and inspectors said activities should be more person-centred.
“People's access to activities needed to improve. Records showed people were involved in activities which included trips into town, shows and entertainers came to visit.” from the report
- 01What activities are available each day if the activities coordinator is away?
- 02How do you use each person's life history, interests and preferences to plan activities?
- 03What changes have been made to activities since this inspection, and how do you know they are helping people avoid boredom?
- 04How have the improvements to staff recruitment identified at the previous inspection been kept in place?
- 05How will you involve our family member in reviewing their care plan and activities?
This was an unannounced inspection of the overall service and all five CQC areas, including care, medicines, staffing, the premises and how the home was managed. This explanation was written from the published report of 2 November 2018 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, November 2017
Rated Requires Improvement; inspectors found kind, personalised care, but weaknesses in recruitment checks, fire safety actions, medicines records and quality monitoring.
Inspectors visited the home without warning on 13 September 2017. They spoke with people living there, relatives, staff and a visiting professional. They observed care and checked care plans, medicine records, staff files and management records.
People were generally positive about the home. Inspectors found caring and respectful staff, suitable training, personalised care plans, activities and good support with food, drinks and health needs. The effective, caring and responsive areas were rated Good.
The home was not always safe or well-led. Employment gaps had not been properly checked, some fire risk actions were still outstanding, and topical medicine records had missing details and signatures. The quality checks had not found these problems before the inspection.
The overall rating Requires Improvement means the home was not consistently meeting the required standards. The report identified one breach, relating to staff recruitment checks.
Kind and respectful care
Inspectors saw staff taking time to reassure people, protect their privacy and support their independence.
“People received care from staff that were compassionate and understanding of their known wishes and preferences.” from the report
Personalised support
Care plans described people's needs and preferences, and staff followed this guidance during care.
“People received care and support that was personalised to meet their individual needs.” from the report
Trained staff
Staff had a range of training, regular supervision and support to develop their skills.
“People benefitted from a staff team that was well trained.” from the report
Activities and involvement
People were offered varied activities and were involved in reviews and decisions about their support.
“There was a wide choice of activities offered to people, ranging from visits of entertainers to daily activities people could attend in the house.” from the report
Recruitment checks
seriousTwo of the four staff files checked had gaps in employment history that had not been explained. This was a breach of the regulations.
“Out of the four records we examined, two members of staff had gaps in their employment history which had not been explored in the course of the process of their recruitment.” from the report
Outstanding fire actions
seriousActions from a fire risk assessment were still incomplete, including a smoke detector in a store cupboard and suspended fire exit signs.
“However, required actions such as installing a smoke detector inside a store cupboard and having suspended fire exit signs were still outstanding.” from the report
Topical medicine records
needs fixingSome cream records did not state the type of cream and three charts had missing signatures. The manager addressed this on the inspection day.
“We also found signature gaps on three charts. Therefore, we could not be sure people received their creams as prescribed.” from the report
Quality checks
needs fixingThe home's audits had not found the recruitment, fire safety and topical medicine problems before inspectors identified them.
“The systems in place to ensure the service was safe and of a high quality, had not effectively identified or monitored improvements required.” from the report
- 01What checks do you now make when an applicant has gaps in their employment history?
- 02Have the smoke detector and suspended fire exit signs identified in the fire risk assessment now been installed?
- 03How are topical creams recorded, and who checks that every application is signed and fully described?
- 04How do your audits now make sure problems are identified and corrected promptly?
- 05How do you ensure care plans and reviews continue to reflect each person's choices, preferences and changing needs?
This was an unannounced inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 15 November 2017 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 OSJCT Lake House
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- November 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
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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