CQC report explained · a nursing home
What the CQC found at Lavender Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2022
Lavender Court was rated Good overall, but inspectors found that staffing, risk monitoring and medicines needed improvement.
This was an unannounced focused inspection on 11 and 13 October 2022. Inspectors spoke with 29 people, 12 visitors and 15 staff. They observed care and checked care plans, medicines records, recruitment files and quality checks.
The overall rating stayed Good. Safe was rated Requires Improvement. Inspectors found enough staff to keep people safe, but the home relied heavily on agency staff. Some agency staff did not introduce themselves, wear clear name badges or know people's needs well enough.
Inspectors also found gaps in risk monitoring and medicines records. Some care plans and risk assessments did not match. Food and fluid monitoring was incomplete, and there were concerns about medicine patches, expiry dates and records for medicines given when needed.
Responsive and well-led were rated Good. People were generally happy, felt safe and could make choices. The home offered activities, welcomed visitors, supported end-of-life care and had managers who monitored quality and worked on improvements.
People felt safe
People described a friendly atmosphere and said they felt safe. Staff knew how to recognise and report abuse, and the home investigated concerns.
“No one has been unkind to me since I have been here.” from the report
Activities and relationships
People had access to activities arranged around their interests and abilities. The home also supported contact with families and links with local groups.
“There were four activity workers who ensured that something was happening at the home every day of the week.” from the report
End-of-life care
People nearing the end of their lives had care plans covering their wishes. Nurses supported comfort and pain relief, and treatment preferences were recorded.
“People could be confident that at the end of their lives they would receive kind and compassionate care.” from the report
Heavy use of agency staff
needs fixingThe home had enough staff on duty, but relied heavily on agency workers. Some people did not know who staff were, and agency staff were not always familiar with their needs.
“We observed agency staff did not always introduce themselves to people and did not wear name badges that could be easily read.” from the report
Risk records did not always match
needs fixingSome care plans and risk assessments gave different instructions. Food and fluid monitoring was also incomplete, which could have led to inconsistent or unsafe care.
“However, care plans and risk assessments were not always compatible.” from the report
Medicines checks
needs fixingMedicine patches were not always rotated as directed and there was no record that they remained in place. Checks of expiry dates and the reasons and outcomes for some medicines given when needed also needed improvement.
“The daily notes did not always record the reason for administering these medicines and the outcome of the administration.” from the report
- 01How many permanent staff now work in each area, and how are you reducing reliance on agency staff?
- 02How do you make sure agency staff introduce themselves, wear clear name badges and understand each person's needs?
- 03What checks now make sure care plans and risk assessments give the same instructions?
- 04How are food and fluid records checked for people whose risk assessments require monitoring?
- 05What new checks are in place for medicine expiry dates, medicine patches and medicines given when needed?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their ratings were carried forward from the previous inspection. This explanation was written from the published report of 2 November 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.
What inspectors found, September 2020
Lavender Court was inspected but not rated; inspectors found good infection control and support for safe visiting.
Inspectors visited the home on 12 August 2020. This was an announced, targeted inspection during the coronavirus pandemic. It focused on infection prevention and control.
Inspectors were assured that the home was managing visitors, social distancing, shielding, admissions, personal protective equipment, testing, hygiene and possible outbreaks. The infection control policy was up to date.
Staff had training and followed current guidance. People were supported to keep in touch with family and friends by phone, video calls and booked safe visits. Staff said they felt supported and kept informed.
This inspection did not give an overall quality rating or a rating for safety. It was a focused check of infection control arrangements, not a full inspection of all aspects of care.
Infection control training
Staff had training and were following current infection prevention and control guidance.
“Staff had received training and were following up to date guidance in infection prevention and control, to minimise risks to people.” from the report
Visitor arrangements
The home checked visitors and provided space for them to put on and remove suitable protective equipment.
“There were systems in place to carry out checks on everyone who visited.” from the report
Contact with families
People could stay in touch with relatives through phone and video calls. Safe visits could also be booked.
“Staff assisted people to keep in touch with family and friends through phone and video calls.” from the report
Staff support
Staff said they were supported by the registered manager and provider, and kept up to date with guidance.
“Staff felt well supported by the registered manager and the provider.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors currently checked and supported to use personal protective equipment?
- 02How do people currently keep in touch with family and friends, including when visits cannot take place?
- 03How are people admitted safely to the home now?
- 04How are staff and residents currently offered testing when needed?
- 05How is the infection prevention and control policy kept up to date?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not provide a full service rating or assess all areas of care. This explanation was written from the published report of 2 September 2020 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 Lavender Court
3 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 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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76 live-in carers within about two hours of Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
“She was not phased by anything, she was adaptable, kind & gave us complete confidence to go away & not worry about a thing!”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.