Lakenham Residential Care Home

Updated 17 November 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Lakenham Residential Care Home is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager was in post and they confirmed they would be applying to register.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with five people using the service and seven members of staff, which included the manager and provider.

We reviewed a range of records. We looked at a variety of records relating to the care and support provided. This included three care files and three staff files in relation to recruitment, and various audits/reports relating to the quality and safety of the service. We requested a variety of records were sent to us relating to staff training and regards the management of the service.

After our visit we sought feedback from relatives and health and social care professionals to obtain their views of the service provided to people. We received feedback from two relatives, and one health and social care professional. We continued to seek clarification from the provider to validate evidence found.

Updated 17 November 2022

About the service

Lakenham is a residential care home providing accommodation and personal care to 19 people in one adapted building at the time of the inspection. The service can support up to 25 people.

People’s experience of using this service and what we found

Staff were deployed appropriately within the home to meet people’s needs in a timely manner.

People said staff were kind and compassionate in their approach. One person commented, “They (staff) are wonderful, they have the right attitude.” Relatives commented, “The staff are lovely” and “The staff go over and above to make residents feel at home, happy and secure. Mum has taken a little while to settle in and their patience and professionalism have really helped. The manager (manager name) inspires me with confidence, along with her team. (Staff names) are respectful and kind to residents. The atmosphere there is happy and relaxed. I enjoy visiting!”

The provider was actively recruiting for staff on an ongoing process via various advertising sources. There were effective recruitment and selection processes in place.

People’s individual risks were identified, and the necessary risk assessment reviews were carried out to keep people safe. For example, risk assessments for falls, skin care, eating and drinking and pain management. Risk management considered people’s physical and mental health needs and showed that measures to manage risk were as least restrictive as possible.

Since our last inspection comfort charts had been introduced where appropriate and handover documentation was more robust to ensure people’s risks were managed safely, consistently and in a timely manner.

People said they felt safe with staff; staff practice showed they knew them well. A person commented, “I feel really safe here, the staff look after me. I have no concerns.” People were at ease and looked comfortable in the company of staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We found the service was working within the principles of the Mental Capacity Act and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met.

People’s medicines were managed so they received them safely. Infection control measures were in place.

The service sought feedback from people who use the service to identify areas for improvement. In response to a change in management in the service and feedback there was a greater emphasis on ensuring people received person-centred care. For example, people developing their life stories in order for care and support to be more personalised according to them as individuals.

People’s equality, diversity and human rights were respected. The service’s vision and values centred around the people they supported. The organisation’s overall statement documented a philosophy of maximising people’s life choices, encouraging independence and people having a sense of worth and value. Our inspection found that the organisation’s philosophy was increasingly being embedded in Lakenham Residential Care Home. For example, people were constantly encouraged to lead rich and meaningful lives to aid their physical and mental health well-being.

A number of methods were used to assess the quality and safety of the service people received. The service made continuous improvements in response to their findings.

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 (published 21 October 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended the provider documented interview questions and answers to further strengthen recruitment practices within the home and strengthened medicines administration practices in line with best practice guidance. At this inspection we found the provider had acted on these recommendations and improvements had been made.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 19 August 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person-centred care, safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lakenham Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.