CQC report explained · a residential care home
What the CQC found at Lavender House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had current, detailed risk plans and there were enough staff to meet their needs. Inspectors found safe recruitment, clean premises, good infection control and well-organised medicines systems.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found that governance systems had improved and were now operated effectively. People, relatives, staff and professionals spoke positively about the way the home was managed.
What inspectors found, November 2023
Rated Good; inspectors found safe, respectful care and stronger oversight after earlier medicines and governance problems.
The inspection was unannounced and took place on 17 October 2023. One inspector spoke with eight people, staff and care professionals. They observed interactions and checked care plans, recruitment and training records, medicines records, staff rotas and quality checks.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, suitable recruitment checks, clear risk plans, safe medicines arrangements, good infection control and people who felt safe. People, staff and professionals also spoke positively about the home and its managers.
The previous inspection found that quality checks were not always effective and rated Well-led as Requires Improvement. Inspectors found that the provider had taken appropriate action, including adding stronger oversight and improving medicines monitoring. The other key question ratings were carried over from the last inspection because they were not inspected this time.
People felt safe
People told inspectors they felt safe and that staff knew how to support them when they became distressed or emotionally unwell.
“I genuinely believe Lavender House is a safe place for me to live.” from the report
Clear risk planning
Risk assessments and management plans were up to date, personal to each person and reviewed when needs changed.
“People had up to date, person-centred risk assessments and management plans in place to help staff keep people safe.” from the report
Medicines improvements
A new medicines recording and monitoring system was introduced after problems in 2022. Inspectors found no recording errors or omissions in the records they checked.
“We found no recording errors or omissions on any medicines records we reviewed as part of this inspection.” from the report
Stronger management oversight
The provider added an area operations manager and increased checks by the registered manager. Inspectors found enough improvement for the governance systems to operate effectively.
“We found enough improvement had been made at this inspection to ensure their governance systems were now operated effectively.” from the report
Respectful support
Inspectors found that people were treated as individuals and received person-centred support from trained staff.
“The residents are not treated as patients at the care home, but people who are all individuals.” from the report
Earlier medicines recording errors
minorThe report says there was an unexpectedly high number of medicines recording errors in 2022. Inspectors found that the new system had significantly reduced the risk and found no errors in the records checked during this visit.
“In response to an unexpectedly high number of medicines recording errors that occurred in 2022 the deputy manager introduced a new medicines recording and monitoring system” from the report
- 01How do you check that the new medicines recording system continues to prevent errors?
- 02What quality checks are now carried out by the area operations manager and the registered manager, and how often?
- 03What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
- 04How will you update my relative's risk plans if their mental health, behaviour or ability to travel independently changes?
- 05How will you involve relatives and community mental health professionals in best-interest decisions if my relative cannot make a specific decision?
This was a focused inspection of Safe and Well-led; the other key question ratings were carried over from the last inspection. This explanation was written from the published report of 4 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, December 2017
Lavender House was rated Good overall; inspectors found kind, safe and personalised care, but management systems required improvement.
This was an unannounced inspection on 30 October 2017. Inspectors spoke with people living in the home, staff and health and social care professionals. They observed care and reviewed care plans, medicines records, recruitment files, training records, complaints and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. People were supported by kind staff who understood their needs, promoted independence and respected their choices. Medicines were managed safely, staff had suitable training, and people received support with health, food, activities and relationships.
The Well-led rating was Requires Improvement. Inspectors found that care records, infection control checks, policies and recruitment procedures were not always fully up to date or followed. The overall rating remained Good, and the home remained Good compared with the previous inspection.
Kind and respectful staff
Inspectors found staff to be empathetic, professional and respectful. People said they liked the staff and enjoyed spending time with them.
“People were supported by staff who were kind and caring in their approach.” from the report
Safe medicines and staffing
Medicines were stored and given safely by trained staff. Inspectors also found enough staff to meet people's care and support needs.
“There were enough staff to support people in a relaxed way.” from the report
Good health support
Staff worked with health and social care professionals and responded to both mental and physical health needs.
“Staff worked closely with health and social care professionals to maintain people's health.” from the report
Personalised support
People were supported to make choices, maintain independence and take part in activities that mattered to them.
“People received care which was personalised to reflect their individual needs and wishes.” from the report
Open management culture
People and staff were consulted, and the provider and manager were described as visible and approachable.
“There was an open culture in the service the registered manager listened to the views of people and staff.” from the report
Care records were not always complete
needs fixingQuality checks did not always ensure that care documentation reflected the support people needed. One person's health condition did not have clear guidance for staff if they became unwell.
“Audit systems did not ensure all the care documentation was up to date and reflected the care and support provided.” from the report
Infection control checks needed improvement
needs fixingInspectors found gaps in hand-washing arrangements and laundry procedures. A full infection control audit had not been completed.
“There had not been a full infection control audit to identify all infection control risks.” from the report
Some policies were not up to date
needs fixingThe report says some policies did not cover important areas, including injections, blood-level monitoring, contingency arrangements and legionella checks.
“The provider had not established systems to ensure the service's policies and procedures were all up to date and adhered to.” from the report
Recruitment procedure was not followed
needs fixingAlthough required checks had been completed in the files examined, the written recruitment procedure did not match the practice being followed.
“The staff recruitment procedure was not being adhered to and did not reflect the practice followed.” from the report
- 01What changes have been made to ensure every care plan clearly records the support and health guidance each person needs?
- 02What infection control audit is now in place, and how are hand-washing and laundry risks checked?
- 03Have the medicines policies been updated to cover injections and monitoring people's blood levels?
- 04How do you check that your recruitment procedure is followed for every new staff member?
- 05How would you support someone whose physical dependency becomes higher than the home can provide for?
This was an unannounced inspection covering all five CQC questions, with the overall rating remaining Good from the previous inspection. This explanation was written from the published report of 23 December 2017 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
4 rated inspections over 9 years: the service has improved, from Requires improvement to Good.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Goodstayed GoodSafe: GoodWell-led: Requires improvement
- October 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 26 April 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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46 live-in carers within about an hour of Brighton and Hove
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Most charge £1,020 to £1,280 a week. 37 can care for a couple. 10 years' experience on average.
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