The Lakes Care Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 1 breach of regulation in relation to the systems in place for governance, as systems for oversight were not being used effectively to identify areas for improvement and ensure appropriate action was taken and embedded. Staff spoke positively about the home manager and felt well supported and positive about working at the home and for the new provider. Partner agencies told us they had noted some improvements but felt further work was needed. The provider was working on an action plan to drive improvements and areas of process needed embedding.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt that the morale in the service had improved and that the team now worked better together. One staff member said, “The management team are approachable, and I would say they are fair. Staff morale is good.” The provider shared that they were working on creating an open and positive culture within the service. They said, “There was a culture of 'you’re doing it wrong.' We now talk through what staff were doing and how they can improve their practice.” The management team acknowledged further improvements were needed. The provider had told us they intended to cancel the regulated activities for treatment of disease disorder and injury, meaning that they would no longer provide care to people with nursing needs. This care was no longer being provided but the provider had not successfully actioned this deregistration process at the time of our assessment.

Since the provider had registered to manage the regulated activities at the location there had been a number of changes in the management team and structure of the service. There had been concerns about the service and the level and speed of improvement being made. Partner agencies raised concerns that information had not always been escalated effectively and statutory notifications which services are required to send to CQC were not always completed. Staff told us they were regular meetings, although the records did not reflect this. One unit manager told us, “We have a managers meeting every Thursday morning and we have regular team meetings with the staff, we have little gatherings.”

Staff spoke positively about the current management team, and told us the manager was approachable, visible and would listen to staff. One staff member said “They’ll take on board and try to resolve things. If I make a suggestion and it can’t happen, they will give me a reason why.”

The provider was in the process of restructuring the management arrangements for the units. This process had not been completed and we will review the impacts of this decision when we next assess this quality statement at the service. At the time of our visit there was no registered manager and although the home manager intended to register with the CQC the application had not yet been successful accepted. Our assessment of process indicated further work was need to support the manager in their role and ensure there were robust systems for oversight which were effectively used, and a full understanding of regulatory responsibilities.

Staff told us they felt able to speak up One member of staff said, “We can get our opinion out there, if we have any concerns we can always speak to the managers and seniors when we need to.”

Records did not always reflect effective processes were being completed, for example that regular meetings were happening.

Staff said the management team treated them all fairly. The home had a diverse workforce, with different ethnicities. Flexibility was available so staff could meet their cultural needs, for example having breaks to pray during their shift.

Records did not always reflect effective processes were being completed, for example that regular meetings were happening and there was insufficient oversight of staff training and supervision. It was not clear how the service was supporting staff's equality diversity and inclusion.

Staff recognised that there were areas for improvement, including the decoration of rooms and record keeping and paperwork. During our site visit the manager and provider acknowledged improvements were needed to the systems for oversight and that audits and checks were not robust and not always completed in a meaningful way.

Processes to ensure governance and oversight were not effective. Audits were in place but were not robust and did not always lead to the required action being completed. For example, audits had not identified the shortfalls in care plans we found including that these were brief and not rewritten when there were major changes in people’s needs. Medicines audits stated there were some missing signatures on the MARs, but no narrative of actions taken was provided to demonstrate lesson learnt and that risk was mitigated as much as possible.

People had visits from children from the local nursery once a week as part of a programme of activities.

The manager told us they had better working relationships with external health care services. For example, there had previously been some challenges in communication between the service and the district nurse team. The manager told us this had improved, and communication was working well. Nobody in the service had any current pressure injuries. However, staff and the manager acknowledged there had been a number of challenges in working with partnership agencies and work to improve this was ongoing.

Whilst partners noted some improvements in working relationships there had also been some challenges with how the service and other agencies worked together. One professional told us that the changes in management had been difficult and their relationships with the management team and not always been positive but felt hopefully that this was now improving.

The service worked alongside a variety of agencies and participated in multiagency meetings to drive improvement within the home. There were areas where partnership working needed to be improved.

Staff spoke positively about the improvement across the home, and were committed to ensuring the service offered good quality care to people. However, records did not always reflect that learning and improvement were embedded into practice.

Staff were working with local authority to develop their knowledge and training. The provider had an action plan and had taken steps to improve aspects of technology such as improving the telephone and internet systems However the action plan had been slow to progress, and it was not clear that when resolution or actions were completed these became fully embedded.