CQC report explained · a residential care home
What the CQC found at The Lakes
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks were not always assessed or managed effectively. Infection-control actions were incomplete, some risk assessments were overdue, and the home did not always follow safeguarding procedures promptly.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- The registered manager did not have effective oversight of safety and quality. Staff said concerns were not always acted on, and monitoring systems had not identified important problems.
What inspectors found, July 2023
The Old Vicarage is rated Requires Improvement; inspectors found ongoing breaches involving safety, safeguarding and quality checks.
This was an unannounced focused inspection in June 2023. Inspectors visited on 8 and 22 June, then returned on 26 June because some safety information was not ready. They spoke with people, relatives and staff, observed care, checked records and looked around the home.
The home was not always safe. Infection-control actions had not all been completed, some risk assessments were overdue, and parts of a bathroom were damaged and had sharp edges. Procedures for responding to allegations of abuse were not followed promptly or reliably.
There were enough staff during the visits, medicines were managed safely, and staff understood how to support people living with dementia. However, checks on safety and quality were not effective, and staff said concerns were not always acted on.
The overall rating remains Requires Improvement, as do Safe and Well-led. The other three question ratings were carried forward from the previous inspection because this visit only assessed Safe and Well-led. The home has been rated Requires Improvement at the last two inspections.
Staffing during visits
Inspectors saw enough staff available to meet people's needs and respond to emergencies during their visits. The provider also increased staffing at busy times after receiving feedback.
“During our visits to the home we saw there were enough staff deployed to meet people's needs and to respond to emergencies.” from the report
Dementia support
Staff showed a good understanding of how to support people living with dementia. They were patient, respectful and used reassurance when people were anxious.
“Staff demonstrated a good understanding of supporting people living with dementia. They followed strategies to provide reassurance when people were anxious and were patient and respectful when assisting people.” from the report
Working with other services
Staff worked with health and social care services to support people's needs. Relatives said staff monitored health and sought medical advice promptly when needed.
“Staff worked cooperatively with other health and social care services to ensure people received the support they needed.” from the report
Unmanaged safety risks
seriousSome infection-control actions and risk-assessment actions had not been completed. Damaged bath panels had sharp edges and were difficult to clean safely.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Safeguarding procedures
seriousThe provider did not always report allegations of abuse promptly to the safeguarding authority or CQC. It also did not immediately follow its procedure after a safeguarding alert was raised during the inspection.
“The provider had failed to operate effective systems and processes to safeguard people from abuse.” from the report
Weak quality monitoring
seriousThe manager's checks did not identify overdue risk reviews, incomplete actions or maintenance problems. Staff also said their concerns were not always acted on.
“The provider had failed to operate effective systems to ensure the quality and safety of the service.” from the report
Mixed feedback from staff and relatives
needs fixingSome staff said staffing levels were sometimes insufficient, although inspectors saw enough staff during their visits. Relatives and staff also gave mixed views about whether their feedback was requested and used.
“Some staff told us there were times more staff were needed to support people and to keep them safe.” from the report
- 01What evidence can you show that all infection-control actions and risk-assessment actions from the inspection have been completed?
- 02How do you now make sure allegations of abuse are reported promptly to the local safeguarding authority and CQC?
- 03How often are environmental risk assessments reviewed, and who checks that they are not overdue?
- 04What has been done to improve the manager's oversight of safety, maintenance and quality?
- 05How do you check staffing levels during busy periods, and what changes were made after staff feedback?
This was a focused inspection of Safe and Well-led, including infection control; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 26 July 2023 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, February 2022
The Old Vicarage was rated Requires Improvement; inspectors found serious infection-control risks, safeguarding failures and weak oversight.
This was an unannounced inspection on 25 January 2022. It began as a targeted inspection after concerns about infection control and management. After inspectors found infection-control concerns, it became a focused inspection of Safe and Well-led.
Inspectors found people were at high risk of coronavirus infection. People who had tested positive were sitting alongside people who had tested negative without social distancing. Visitors were not asked for proof of a negative test or vaccination status. A safeguarding allegation had also not been reported to the local authority.
There were some positive findings. Staffing levels were sufficient, staff were caring, medicines were managed safely and people and relatives spoke positively about the home. However, quality checks did not identify or fix several important problems. The overall rating fell from Good at the previous inspection to Requires Improvement.
Enough staff
Inspectors saw enough staff deployed to meet people's needs. Staffing levels were monitored by the registered manager.
“We observed there were sufficient staff deployed to meet people's needs.” from the report
Kind interactions
Inspectors observed caring interactions. People and relatives were positive about the staff's care and approachability.
“We observed caring interactions throughout the inspection.” from the report
Medicines
Medicines were stored, administered and recorded safely. Staff had suitable training and practice checks had been completed.
“Medicines were stored and managed safely. Staff were suitably trained to administer medicines and checks on their practice had been carried out.” from the report
Positive leadership relationships
People and relatives spoke positively about how the home was managed. The registered manager worked with other agencies to coordinate care.
“People and relatives spoke positively about the way the home was managed.” from the report
Coronavirus infection control
seriousPositive and negative residents were seated together without social distancing, and visitors were not checked for a negative test or vaccination status. Inspectors said this placed people without coronavirus at very high risk of infection.
“This meant people without the virus were placed at very high risk of being infected.” from the report
Safeguarding reporting
seriousThe provider investigated allegations of abuse but did not report them to the local authority. This meant the local authority could not oversee the investigation.
“This meant the local authority had no oversight of the investigation.” from the report
Weak safety oversight
seriousEnvironmental risk assessments were missing or incomplete, and there was no outbreak risk assessment available during the inspection. The fire risk assessment had also expired.
“The provider had failed to operate effective systems to ensure the quality and safety of the service.” from the report
Recruitment records
needs fixingInspectors found gaps in the recruitment records they checked. The registered manager said these would be addressed.
“Recruitment processes were not always effective. We looked at two staff files and noted shortfalls in the documentation.” from the report
Limited resident feedback
needs fixingNo satisfaction survey had been carried out in 2021, and inspectors found evidence of only one residents' meeting. This gave people limited formal opportunities to comment on the home.
“This meant people had limited opportunities to provide feedback on their experience of living in the home.” from the report
- 01What changes have been made to separate people who test positive for coronavirus from those who test negative?
- 02How are visitors' negative tests or vaccination status checked now?
- 03How are safeguarding allegations reported to the local authority and checked by management?
- 04Which environmental and coronavirus outbreak risk assessments are now in place, and when were they last reviewed?
- 05What has been done to complete recruitment records and restart residents' meetings and satisfaction surveys?
This was a focused inspection of Safe and Well-led after concerns about infection control and management; Effective, Caring and Responsive were not assessed during this visit. This explanation was written from the published report of 24 February 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.
Every inspection of The Lakes
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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