17 June 2021
During an inspection looking at part of the service
The service is purpose built and has accommodation over three floors. Facilities within the service include a spa area, a cinema room, a fine dining room and a bistro café and shop.
People’s experience of using this service and what we found
Since the last inspection the provider had improved the systems to monitor accidents and incidents and the incidents of falls had significantly reduced. People’s care plans had been improved to include more information about how they preferred to take their medicines. This demonstrated a commitment to lessons learnt, to continuously improve the care of people living at the service.
Most of the people living at the service, relatives and staff spoken during the inspection confirmed staffing levels were good and staff were available when needed. Whilst some people that required the support of two staff for moving and handling and personal care told us sometimes, they had to wait longer periods for two staff to be available.
The provider used a dependency tool to calculate the number of care staff hours needed to meet the dependency levels of people using the service. Records showed that staffing hours and dependency levels were regularly reviewed and updated by the registered manager and senior management team.
The registered manager confirmed they and the human resources department were now closely monitoring staff sickness and absence management systems were being followed. Staff rota’s and timesheets evidenced that enough numbers of staff were available to meet people’s needs. On the day of the inspection staff were observed to spend time with people and work unrushed.
Robust staff recruitment procedures were followed. At the time of the inspection the provider was actively recruiting more staff for the service. Some new staff had been recruited and were undertaking induction training.
People using the service told us the staff administered their medicines safely. Medicines were stored securely and administered to people as prescribed. Staff were trained in the safe administration of medicines and their competency was assessed before they administered medicines to people.
The environment was clean, and people were protected from the spread of infection including COVID -19. Staff used personal protective equipment such as gloves and aprons, which were readily available. Staff undertook routine COVID -19 testing and government guidance regarding isolation was followed in response to any positive results. Upon arrival at the service visitors were asked to undertake a rapid flow COVID-19 test and provided with personal protective equipment (PPE) before entering the service.
The registered manager acted in line with the duty of candour requirements. People confirmed they felt supported to raise any concerns or complaints. CQC had been kept informed of notifiable events that had happened at the service. A notification is information about important events, which the provider is required to send us by law in a timely way. The ratings from the last comprehensive inspection were displayed in the front entrance of the service and on the provider website.
Records showed that rigorous management quality assurance processes were followed. Audits were carried out on all aspects of the service to identify areas for further development, and action plans were completed in a timely way.
Feedback on people’s experiences and the quality of the service was sought. Quality assurance surveys had been sent out to people using the service, relatives, staff and healthcare professionals. At the time of the inspection the provider was waiting on the results to complete their six-monthly quality evaluation.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update:
The last rating for this service was requires improvement (report published 29 October 2020).
Why we inspected
The inspection was prompted in part due to anonymous whistle-blower concerns received about staffing levels. The registered manager had responded promptly to all the concerns raised and fully co-operated with CQC and the local safeguarding authority in providing information and in carry out safeguarding investigations. A decision was made for us to inspect and examine those risks and we found no evidence that people were at risk of harm from the concerns. Please see the Safe and Well-Led sections of this report.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed to Good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lakeview Lodge Care Home on our website at www.cqc.org.uk
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.