Lakeshore Care Ltd, a domiciliary care agency serving 29 people in Sutton, was rated Good across all five key questions at its July 2023 inspection. The service demonstrated safe, person-centred care with strong governance, stable staffing, effective medicines management, and consistently positive feedback from people and their relatives.
Strengths
· People and relatives consistently reported feeling safe, well-treated and satisfied with the care received.
· Stable staff team providing continuity of care with visits at times convenient to people.
· Robust safeguarding procedures with staff knowledgeable about recognition and reporting of abuse.
· Safe recruitment practices including DBS checks, references and right-to-work verification.
· Medicines administered safely with annual competency checks and audits of records by senior staff.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Continuous learning and improving careGood
Lakeshore Care Ltd improved from 'Requires Improvement' to 'Good' across all five key questions following remediation of medicines recording and staff continuity issues identified at the previous inspection. The service demonstrated safe, person-centred care with well-trained, consistent staff, effective governance systems, and a positive, open culture.
Concerns (1)
minorSupervision / appraisal: “the records we saw for the one to one supervision meetings were brief and the registered manager agreed they needed to be expanded in order to maintain an accurate record”
Strengths
· Medicines administration records were kept and maintained on people's care files, with only trained staff permitted to administer medicines.
· People reported feeling safe and appreciated consistency of regular carers who understood their needs.
· Comprehensive risk assessments were carried out collaboratively with people and their relatives.
· Staff received a wide variety of training including dementia, continence care, moving and handling, MCA, and safeguarding.
· An effective complaints policy and procedure was in place and complied with in a timely manner.
Lakeshore Care Ltd required improvement overall due to unsafe medicines recording practices and poor care continuity caused by high staff turnover and inconsistent care worker allocation. The service performed well in effectiveness, responsiveness, and leadership, with robust safeguarding, individualised care planning, and an open management culture.
Concerns (5)
criticalMedication management: “Some care workers initialled the MAR with their first name only and others ticked the record. We also noted there were a number of gaps on the MAR where it could not be established from the record if medicines had been given.”
moderatePerson-centred care: “During August and October 2015 we found examples where a person who required a single care worker per visit, had eight different workers in a seven day period.”
moderateStaffing levels: “The registered manager, who told us they had continuous difficultly recruiting and retaining staff.”
moderateRecord keeping: “The provider had also not carried out recent checks to make sure the medicines records were completed as required to confirm that people received their medicines as prescribed.”
minorSupervision / appraisal: “The registered manager also acknowledged the majority of care workers had not had an appraisal in the previous year, as there had been a high turnover of staff.”
Strengths
· Staff trained in safeguarding and able to identify signs of abuse and take appropriate action.
· Robust pre-employment checks including criminal records checks, identity verification, and employment history review.
· Risk assessments and Client Events log in place; registered manager analysed patterns to minimise reoccurrences.
· Care plans individualised, reviewed every six months, and focused on promoting independence and people's choices.
· Out-of-hours on-call senior staff rota ensured continuity and support for care workers.
Quality-Statement breakdown (16)
safe: Medicines administration records incomplete and inconsistent, creating accountability gaps.Requires improvement
safe: Safeguarding training in place; staff able to identify and report concerns.Good
safe: Pre-employment checks completed robustly including DBS and identity verification.Good
safe: Risk assessments and significant event logging in place with management oversight.Good
effective: Mandatory training programme in place and refreshed regularly.Good
effective: Supervision held every two to three months; appraisals not completed for majority of staff.Requires improvement
effective: MCA principles understood; consent sought before care is provided.Good
Lakeshore Care Ltd was rated Requires improvement overall at its June 2015 inspection, with three regulatory breaches identified: care plans not reviewed in a timely manner (Regulation 9), complaints policy not accessible to people (Regulation 16), and failure to notify CQC of an abuse allegation (Regulation 18). Safe, effective, and caring domains were rated Good, reflecting sound safeguarding, training, and person-centred practice.
Concerns (3)
criticalCare planning: “All the care plans and risk assessments we looked at had a default review date of May 2015 and there was nothing to indicate the reviews had been completed.”
criticalGovernance: “The registered manager had not informed the CQC of a significant incident where there were allegations that a person had been abused.”
moderateComplaints handling: “The policy was not routinely given to people or their representatives as part of the information given to them about the service.”
Strengths
· Staff demonstrated clear knowledge of safeguarding signs, symptoms, and escalation procedures
· Robust recruitment checks including references, DBS, and identity documentation
· Consistent care worker allocation providing continuity and familiarity for people
· Care workers matched to people by language, cultural background, and dementia experience
· Accidents and incidents recorded, analysed for trends, and acted upon to prevent reoccurrence
This focused inspection of Lakeshore Care Ltd on 1 October 2015 checked progress against three breaches found at the June 2015 comprehensive inspection, finding that legal requirements had now been met in relation to care planning, complaints accessibility, and CQC incident notifications. Ratings for 'Responsive' and 'Well-led' remained 'Requires improvement' as consistent good practice over time had not yet been demonstrated.
Concerns (4)
criticalCare planning: “care plans had not been updated and might not have reflected people's needs at the time. Care plans we looked at had a default review date and there was nothing to indicate the reviews had been completed”
criticalIncident learning: “people were not protected from the risks of poor care as the registered manager had not informed CQC of significant incidents that had occurred.”
criticalGovernance: “The provider did not notify the Care Quality Commission (CQC) of significant incidents which they are required to do under legislation.”
moderateComplaints handling: “The provider's complaints policy was not readily available or routinely given to people who used the service.”
Strengths
· Provider followed their action plan and took appropriate steps to address all three breaches identified at the June 2015 comprehensive inspection.
· Provider wrote to people and their representatives acknowledging care plan shortfalls and prioritising immediate reviews for those who required them.
· An easy-to-read complaints leaflet was developed and posted to all people receiving a service.
· Mechanisms were put in place to ensure CQC notifications were made and incidents reviewed and referred to appropriate agencies.
· Care staff were kept informed of changing needs via emails and regular team meetings during the care plan review period.
Quality-Statement breakdown (3)
responsive: Care plans reviewed and updated to reflect current needsRequires improvement
responsive: Complaints policy accessible and available to people using the serviceRequires improvement
well-led: Notification of significant incidents to CQCRequires improvement
effective: People's nutritional and health needs monitored and supported appropriately.
Good
caring: High number of different care workers per person undermined continuity and relationship building.Requires improvement
caring: Care plans promoted independence; care workers respectful of privacy and dignity.Good
responsive: Care plans individualised, reviewed six-monthly, and updated following changes in need.Good
responsive: Complaints policy accessible; people encouraged to raise concerns; complaints log maintained.Good
responsive: People supported to access community and maintain social connections.Good
well-led: Registered manager met CQC notification requirements and had clear legal awareness.Good
well-led: Quality monitoring systems in place including spot checks and satisfaction surveys.Good
well-led: Open and approachable leadership culture reported by staff and people using the service.Good
caring: Continuity of care workers
Good
caring: Promoting independenceGood
responsive: Care plan review and currencyRequires improvement