CQC report explained · a residential care home
What the CQC found at Lavender House Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always stored securely and fridge temperatures were not consistently recorded. Fire safety records were incomplete, although the broken stairlift arm was fixed during the inspection.
- Effective?
- Requires improvement
- One person's extended respite stay had not led to a full assessment and care plan. Some staff needed updated training, and some mental capacity decisions still needed review.
- Caring?
- Good
- People and relatives said staff were kind, respectful and caring. Staff involved people and relatives in decisions and supported privacy and dignity.
- Responsive?
- Good
- Care plans reflected personal care needs and preferences and were reviewed when needs changed. Feedback about activities was mixed, with some relatives wanting more stimulation.
- Well-led?
- Requires improvement
- The provider's audits did not reliably identify problems or promote improvement. There was no registered manager in post at the time, although an application was being processed and the manager had begun making changes.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found kind and respectful care, but medicines management and oversight were not safe enough.
Inspectors visited unannounced on 30 May and 14 June 2022. Inspection activity continued until 22 June. They spoke with people, relatives, staff and managers, and checked care plans, medicines records, recruitment files, audits and safety documents.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also Requires Improvement. Caring and Responsive were rated Good.
Inspectors found problems with medicines storage and temperature records. Fire safety checks were not consistently recorded, some equipment needed attention, and audits did not identify important risks. The provider acted on some issues during the inspection, but improvements still needed to be embedded.
Kind and respectful staff
People and relatives described staff as friendly, kind and caring. Inspectors also found that people were treated with dignity and involved in everyday decisions.
“People and relatives told us staff were friendly, kind and caring.” from the report
Food and hydration
People had choices and generally spoke positively about the meals. Nutrition and hydration needs were recorded, with extra support and professional referrals when needed.
“People told us they enjoyed their meals and were given a good variety of options.” from the report
Personalised personal care
Care plans included people's personal care needs and preferences. Staff worked patiently with people who were reluctant to accept personal care.
“People's care plans reflected their needs and preferences around their personal care.” from the report
Staffing and recruitment
People and relatives felt there were enough staff. The provider used recruitment checks and the manager assessed staffing levels against people's needs.
“People and relatives felt there were enough staff.” from the report
Medicines safety
seriousMedicines were sometimes accessible to people and were not always stored suitably. Fridge temperature checks were missing on 18 days in May 2022, creating uncertainty about whether some medicines were kept at the right temperature.
“The failure to operate safe systems for the management of medicines was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Weak audits and oversight
seriousThe provider's audits did not identify problems found by inspectors, including medicines issues. The provider had also not acted on many medicines recommendations made by the Clinical Commissioning Group.
“The failure to implement effective systems to assess, monitor and improve the quality and safety of the service was a breach of Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Incomplete assessments and capacity records
needs fixingA person staying longer than planned still had only a limited care plan. Some earlier decisions about care were not specific enough to show that they were least restrictive and in the person's best interests.
“However, people's needs were not always fully assessed when their temporary respite stay at the service was extended.” from the report
Training and environment updates
needs fixingSome staff needed updated training in fire safety, moving and handling, and medicines administration. Parts of the building, including worn carpet and kitchen work surfaces, also needed updating.
“Some staff required training updates in areas of their role to ensure their knowledge and skills were current.” from the report
Activities
minorRelatives gave mixed views about meaningful activities. Some felt the home needed to provide more entertainment and stimulation.
“The only thing that is possibly lacking is perhaps more entertainment and activities.” from the report
- 01What changes have been made to medicines storage, fridge temperature checks and controlled drug audits since the inspection?
- 02How do you now check that audits identify risks and lead to lasting improvements?
- 03Has every person staying for an extended respite period received a full needs assessment and care plan?
- 04Have staff completed the planned updates to fire safety, moving and handling and medicines training?
- 05What additional activities and stimulation are now available for people who want them?
This was an unannounced inspection of the newly registered service covering all five key questions, with visits on 30 May and 14 June and inspection activity ending on 22 June 2022. This explanation was written from the published report of 3 August 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.
Every inspection of Lavender House Care Home
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- August 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019
Registered with the Care Quality Commission on 1 November 2019.
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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Most charge £980 to £1,300 a week. 39 can care for a couple. 11 years' experience on average.
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