CQC report explained · a residential care home
What the CQC found at Lavender House Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2022
Inspected but not rated; inspectors found good COVID-19 infection control and a clean home, but this was not a full inspection.
The inspection took place on 4 February 2022 and was announced one day beforehand. It was a targeted inspection focused on infection prevention and control during the COVID-19 pandemic, as well as staffing pressures.
Inspectors found that the home was following national guidance. Staff used protective equipment safely, supplies were available, people and staff were tested regularly, and visiting arrangements followed current guidance.
The home was clean and hygienic, with cleaning schedules and extra cleaning procedures. Inspectors also found that the home supported people and relatives to understand COVID-19 safety measures.
The service was inspected but not rated. This means the visit did not give an overall quality rating or a full set of ratings for all five areas of care.
Infection control
Inspectors found that the home was following infection prevention measures. This included safe PPE use, regular testing and arrangements to prevent and manage outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Clean environment
The home had cleaning schedules, PPE stations and extra procedures to sanitise the building regularly.
“The home was clean and hygienic. Cleaning schedules were in place and PPE stations placed around the home.” from the report
Visiting and communication
Relatives spoke positively about visiting and being kept informed about changes to arrangements.
“Relatives spoke very positively about visiting and the communication from the service.” from the report
Dedicated staff team
The report describes a dedicated team supporting people in line with national guidance.
“The service had a dedicated staff team. People were supported in the service in accordance with national guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01How are current staffing pressures affecting the people living in the home?
- 02How will you tell relatives about any changes to visiting requirements?
- 03How often are people and staff currently tested for COVID-19?
- 04How do you check that cleaning schedules and extra cleaning procedures are being followed?
- 05When was the infection prevention and control policy last reviewed, and what has changed since this inspection?
This was a targeted inspection of infection prevention and control and staffing pressures; it did not provide ratings for the other areas of care or an overall quality rating. This explanation was written from the published report of 3 March 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, October 2019
Rated Good overall, but inspectors found weaknesses in medicines records, care plans and management oversight.
This was an unannounced planned inspection on 19 September 2019. One inspector spoke with people, visitors, staff and managers, and reviewed care plans, staff files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People were found to be treated with kindness and respect, supported by enough trained staff, offered suitable food and activities, and helped to access healthcare.
Well-led was rated Requires Improvement. Records about medicines and people's care were not always complete or accurate, and some required notifications had not been sent to the CQC. The overall rating remained Good.
Kind and respectful care
People said staff were kind, knew them well and respected their privacy, dignity and independence.
“People were treated with dignity and respect by kind and caring staff that knew them well.” from the report
Enough trained staff
Inspectors found enough safely recruited staff on duty. People did not have to wait long for support.
“Sufficient numbers of safely recruited staff were deployed.” from the report
Food and hygiene
The home was clean and hygienic. People's dietary needs and preferences were catered for, and food safety received the highest score.
“The food standards agency had awarded the service the highest score of five stars for food safety.” from the report
Activities and choice
People had access to activities, outings and entertainers that reflected their interests. They could make choices about their daily routines.
“Activities were personalised to people's preferences and hobbies.” from the report
Medicine stock records
needs fixingRecords showing the amount of medicines in stock were not always accurate or up to date. The report says a shortfall in recording quantities received on medicine records was addressed during the inspection.
“Records relating to the amount of medicines in stock were not always up to date and accurate.” from the report
Care plan information
needs fixingInformation from paper assessments was not always transferred to digital care plans. Staff were also not consistent about where they recorded information, making the latest information difficult to find.
“Some information held on paper records had not been transferred onto the computerised care planning system.” from the report
Management oversight
needs fixingAudits had not found some inaccurate or incomplete records. Some statutory notifications about authorised DoLS had not been sent to the CQC, although this was addressed during the inspection.
“Some statutory notifications had not been submitted to the CQC as required when a DoLS had been authorised.” from the report
- 01How do you now check that medicine stock records are accurate and up to date?
- 02How do you make sure information from paper assessments is transferred fully into digital care plans?
- 03Where should staff record changes to care, and how do you make sure they can find the latest information?
- 04How do you ensure all required statutory notifications, including DoLS notifications, are sent to the CQC?
- 05What changes have been made since the inspection when Well-led fell from Good to Requires Improvement?
This was an unannounced planned inspection covering all five key questions, with the overall rating remaining Good. This explanation was written from the published report of 25 October 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 Residential Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Lavender House Residential Home →
- October 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Lavender House Residential Home →
- March 2017Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 20 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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