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.
- Safe?
- Good
- Risks such as falls and sore skin were assessed, monitored and reviewed. Medicines, safeguarding, staffing and infection control were found to be managed safely.
- Effective?
- Good
- This report does not give a rating or findings for Effective.
- Caring?
- Good
- This report does not give a rating or findings for Caring.
- Responsive?
- Good
- This report does not give a rating or findings for Responsive.
- Well-led?
- Good
- The home had regular audits, action plans and clear staff responsibilities. People and relatives said they felt listened to and spoke positively about the home.
What inspectors found, November 2023
Lavender Court was rated Good; inspectors found people were safe and the home was well managed.
This was an unannounced inspection on 31 October 2023. One inspector and an Expert by Experience spoke with 4 people, 10 relatives or friends, and members of staff. They also checked 6 people's care records, medicines, staffing checks and management records.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed and reviewed, medicines were managed safely, there were enough staff, and safeguarding procedures were followed.
Inspectors also found regular audits and action plans to improve the service. People and relatives spoke positively about the care and management. The Safe rating improved from Requires Improvement at the previous inspection, while Well-led remained Good.
Risk management
People's individual risks were recorded and reviewed, with plans explaining how staff should keep them safe.
“People had detailed plans in place identifying when they were at risk and actions taken to keep people safe.” from the report
Medicines
Inspectors found that medicines were stored, managed and given safely. Records showed that as-required medicines were given when needed.
“Medicines were stored, managed and administered in a safe way.” from the report
Staffing
Inspectors found enough staff available to support people, and recruitment checks were completed before staff started work.
“There were enough staff available for people and they did not have to wait for support.” from the report
Management checks
The home used audits covering areas such as medicines, infection control and mealtimes. Action plans were used where improvements were needed.
“Audits were consistently completed within the home, they covered areas such as medicines management, infection control and mealtime audits.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and review my relative's specific risks, such as falls or sore skin?
- 02How will you make sure my relative receives medicines on time, including any medicines prescribed to be taken when needed?
- 03How do you check that there are enough suitably checked and trained staff on each shift?
- 04What action plans are currently open following your audits, and when will they be completed?
- 05How can my family give feedback or raise a concern, and how will we be kept informed?
The report gives ratings only for Safe and Well-led; it does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 16 November 2023 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, July 2018
Rated Good overall, but Safe requires improvement because call bell responses and medicines records were not always reliable.
Inspectors made an unannounced, comprehensive inspection visit on 31 May and 1 June 2018. They spoke with people, relatives, staff and a health professional. They also observed care and checked care plans, medicine records, staff files and quality checks.
The overall rating was Good. Effective, Caring, Responsive and Well-led were all rated Good. The Safe rating was Requires Improvement. People generally felt safe and cared for, but inspectors found delays in answering call bells and some problems with medicine recording and reporting.
This was the first inspection since the provider changed. Inspectors had received concerns about earlier care, including risks linked to health, choking, nutrition, pressure damage, nursing care and staff training. They found that many systems had since improved, but some work was still continuing.
Improved risk management
Risk assessments had become more detailed and individualised. Staff understood how to manage important risks such as choking and pressure damage.
“We saw a new recording system was in place that included more detailed and informative risk assessments.” from the report
Kind and respectful care
Staff were seen speaking kindly, protecting privacy and dignity, gaining consent and supporting people's independence.
“We saw staff consistently asked people for their consent before; for example providing personal care or support.” from the report
Clean environment
The home was visibly clean and staff followed infection control practices.
“We found the provider had systems in place to ensure a good standard of cleanliness was maintained and people were protected from cross infection” from the report
Management learning
The provider had responded to concerns from commissioners and other agencies, and had introduced monitoring in areas such as medicines, falls, fluids and weight.
“The provider had taken on board advice from external agencies such as commissioners to assist their learning.” from the report
Delayed call bell responses
seriousInspectors saw one person wait 13 minutes for help after using the call bell. Other calls were answered quickly, but management said they would consider auditing response times.
“We observed it was 13 minutes before the call bell was answered by staff.” from the report
Noisy mealtimes
minorThe main dining area was very noisy and busy. Management recognised that mealtimes should be calmer, especially for people living with dementia.
“We observed people's dining experience (in the main dining area) and we found this to be very noisy with many people in the room.” from the report
Activities needed improvement
needs fixingPeople had access to some activities, but feedback showed that more activities and entertainment were wanted. The home planned to employ a dedicated activities worker.
“The management told us they had heard from people and their relatives from a recent survey, as shown to us, that activities for people needed improvement.” from the report
Care records still being updated
needs fixingMost care records had improved, but some still needed updating. One person's guidance about responding to seizures was updated during the inspection.
“We found some limited exceptions, for example where there was some update needed in terms of how staff would response to a person having seizures.” from the report
- 01How quickly are call bells answered now, and can you show us recent response-time checks?
- 02How are medicine errors recorded, reported to management and reviewed to prevent them happening again?
- 03What activities are now available, and how are they matched to residents' interests and needs?
- 04What changes have been made to make mealtimes quieter and more suitable for people living with dementia?
- 05Has the manager's CQC registration application been completed, and who is legally responsible for managing the home now?
This was an unannounced comprehensive inspection covering all five key questions and the overall rating; it was the first rating under the new provider. This explanation was written from the published report of 7 July 2018 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
2 rated inspections over 5 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2018GoodSafe: Requires improvementWell-led: Good
- September 2017
Registered with the Care Quality Commission on 1 September 2017.
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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