CQC report explained · a residential care home
What the CQC found at Lavender House and Primrose Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors looked only at medicine safety. They found several weaknesses but also saw that staff administered medicines safely and that the home took immediate corrective action.
- Effective?
- Good
- Not assessed in this targeted inspection.
- Caring?
- Good
- Not assessed in this targeted inspection.
- Responsive?
- Good
- Not assessed in this targeted inspection.
- Well-led?
- Good
- Not assessed in this targeted inspection.
What inspectors found, October 2021
Lavender House and Primrose Lodge was inspected but not rated; inspectors found medicine errors and several medicine controls needing improvement, with immediate action taken.
This was a targeted inspection on 15 September 2021. Inspectors looked only at the safe management of medicines because CQC had received concerns about medicine errors. They spoke with three staff members and reviewed six people's medicine records.
The home had experienced 15 medicine errors since September 2020, although no one had suffered serious harm. Inspectors found problems with access to some medicines, recording fridge temperatures, checking medicine stock balances and disposing of one medicine after its expiry date. One dose of the expired medicine had been given.
The home took immediate action during the inspection. It changed medicine cupboard and fridge access, removed the expired medicine, reminded staff how to record fridge temperatures and revisited staff training. Staff were trained to give medicines, and inspectors saw medicines being given safely.
Trained staff
Staff who administered medicines had training and had their ability checked. Inspectors saw medicines being given safely and in a caring way.
“Staff administering medicines had received medicines training. Competency assessments had been completed to ensure they were able to administer medicines safely and appropriately.” from the report
Errors investigated
Medicine incidents were recorded and investigated. The home analysed patterns and put measures in place to reduce repeat errors.
“Medicines incidents had been recorded and investigated. There were clear measures in place to address the errors that had occurred and improve safe medicine management.” from the report
Medicines records
The medicine administration records reviewed showed medicines were being given as prescribed, with clear instructions and checks by a second staff member.
“The MARs we reviewed, showed people's medicines were being administered as prescribed.” from the report
Action during inspection
The home acted immediately to restrict access to medicines and remove the expired medicine.
“Following the inspection all codes were changed to ensure access was restricted to medicines trained staff.” from the report
High number of errors
seriousThe home had recorded 15 medicine errors since September 2020. No serious harm was reported, but this was the reason for the targeted inspection.
“The service had experienced 15 medicine errors since September 2020.” from the report
Expired medicine given
seriousOne medicine had not been removed after its in-use expiry period, and one dose was given after expiry. The medicine was removed and the home investigated what happened.
“One dose of this medicine had been given since it's expiry.” from the report
Medicine access
needs fixingAll staff could initially access medicine cupboards, including medicines that should have been limited to trained staff. Refrigerated medicines were also not initially kept in a locked fridge.
“Access to medicines requiring refrigeration were not restricted to authorised staff.” from the report
Incomplete checks
needs fixingFridge temperature records were not completed correctly, and medicine stock balances did not match the medicines held. Staff training and recording processes were addressed after the inspection.
“Staff had not been recording the balance correctly.” from the report
- 01How are you now checking that only staff trained to give medicines can access medicine cupboards and the medicines fridge?
- 02How do you record and review fridge temperatures for refrigerated medicines?
- 03How are medicine stock balances checked now, and how often are full checks completed?
- 04What changes have been made to prevent medicines being used after their in-use expiry date?
- 05What has happened with medicine errors since the 15 errors recorded from September 2020?
This was a targeted inspection of specific medicine safety concerns only; it did not assess all of the Safe question or the other four questions, and it did not change the previous Good rating. This explanation was written from the published report of 20 October 2021 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, March 2019
Lavender House and Primrose Lodge was rated Good; inspectors found kind, safe care, with some records and medicines storage issues to address.
This was an unannounced, comprehensive inspection on 6 and 7 March 2019. Two inspectors reviewed care plans, daily records, medicines charts, incidents, audits and policies. They spoke with staff and met people living at the home.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, well-managed medicines overall, good training and kind interactions. People had choices, activities and support suited to their needs.
There were some shortfalls. The medicines storage room in Primrose Lodge was regularly too warm, although action was taken immediately. Some care and health plans repeated information and were not always updated consistently. There were also no end of life care plans because nobody needed this support at the time.
Kind and respectful care
Inspectors saw warm, caring interactions. Staff knew people well and supported their communication, privacy, choices and independence.
“We observed kind and caring interactions. Staff responded to people's requests for hugs and human contact.” from the report
Good staff training
Staff had training in core areas and received extra training when people's needs changed, including catheter care.
“People were supported by a staff team who were well-trained to meet their needs.” from the report
Personalised activities
People were supported to take part in activities they enjoyed and to build independence through everyday tasks.
“People participated in a broad range of activities. These included horse riding, karaoke, attending a weekly disco, playing bingo, and attending hydrotherapy swimming.” from the report
Strong management
The management team used audits, staff discussions and outside reviews to identify areas for improvement. Staff said they felt supported to raise concerns.
“There was an open culture of wanting to receive feedback about the service.” from the report
Medicines storage temperature
needs fixingThe medicines room in Primrose Lodge regularly went above the recommended maximum temperature. The manager acted immediately by using air conditioning and telling staff about the requirement.
“We identified that medicines were stored at too high a temperature in Primrose Lodge, above the recommended 25 degrees Celsius (°C).” from the report
Incomplete epilepsy information
needs fixingOne person's heat-sensitive epilepsy needs were not fully documented. Staff knew the person's needs, but the written plans did not explain all the safety measures being used.
“One person had temperature sensitive epilepsy, however their support and health plans did not reflect this.” from the report
Care plans not always consistent
needs fixingInformation was duplicated across care and health plans. When people's needs changed, updates were not always made consistently in every place.
“Some of the information was duplicated in the different plans. This meant ensuring the information remained up to date throughout the plans was not always consistent.” from the report
No end of life plans
needs fixingNobody was receiving end of life care during the inspection, but the home had no plans recording people's wishes or those of their next of kin.
“There were no end of life support plans in place to document the wishes of people and their next of kin.” from the report
- 01How do you now monitor the temperature of the medicines storage room in Primrose Lodge?
- 02How do you make sure changes in a person's needs are updated across every care and health plan?
- 03How are the safety measures for people with heat-sensitive epilepsy recorded and checked?
- 04Have end of life care plans now been discussed and completed with people and their families?
- 05How will you continue developing the active support approach so people can do more for themselves?
This was an unannounced comprehensive inspection covering the overall service and all five CQC questions; the previous March 2016 inspection also rated every area Good. This explanation was written from the published report of 19 March 2019 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 House and Primrose Lodge
2 rated inspections over 3 years: the service has held its Good rating throughout.
- October 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Lavender House and Primrose Lodge →
- March 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Lavender House and Primrose Lodge →
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Registered with the Care Quality Commission on 1 July 2014.
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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