CQC report explained · a nursing home
What the CQC found at Lavender Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Staffing numbers were judged sufficient, including arrangements for occasional night-time sickness. Inspectors were also assured that infection prevention, personal protective equipment and testing arrangements were in place.
- Effective?
- Requires improvement
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- The new manager was making changes and quality checks were being used. Some staff raised concerns about the manager's communication, morale and training levels, with action planned or already taken.
What inspectors found, November 2020
Inspected but not rated; the previous Good rating remained, with staffing and infection controls in place, but some management issues were being addressed.
This was a targeted inspection on 24 September 2020. Inspectors followed up concerns about management, care standards and staffing. They spoke with people, relatives and staff, observed care, and checked records such as care plans, medicines audits, staff rosters and complaints.
Inspectors found enough staff to meet people's needs. They found infection control measures for Covid-19 were in place. People and relatives were generally positive about the care and said they could raise concerns.
The new manager was making changes to improve care and the service's culture. Some staff raised concerns about the manager's communication, morale and training levels. Action was being taken to address these issues.
This inspection did not give new ratings. It only checked specific parts of Safe and Well-led. The previous overall rating was Good and remained unchanged.
Staffing
Inspectors observed enough staff to support people and meet their needs. Staffing plans were based on people's dependency and needs.
“We observed there were sufficient staff to support people and meet their needs.” from the report
Infection control
The home had measures in place to prevent and manage infection. Inspectors were assured about personal protective equipment, testing, social distancing and admissions.
“We were assured that the provider was using PPE effectively and safely.” from the report
People could speak up
People and relatives said they could raise issues. Complaints had been investigated and relevant action had been taken.
“People and relatives felt overall the service was well-led.” from the report
Improvement work
The new manager and provider had identified priorities and were using action plans and audits to improve the service.
“The manager and provider understood the priorities for the service, and action was being taken to address them.” from the report
Manager's communication
minorSome staff felt the manager's communication could be less sharp. This was fed back to the provider, which acted immediately and considered communication training.
“Some reported on occasions, the manager made their point of view, too loudly or vigorously.” from the report
Staff training
minorStatutory training compliance had improved but was 85% at the time of the inspection. The provider had identified training and supervision as areas needing further work.
“Staff's statutory training compliance had been increased and was now at 85%.” from the report
Unpaid handovers
minorCare staff were encouraged to attend handovers but were not initially paid for this time. The manager said this would change from 5 October 2020.
“whilst staff's attendance was not compulsory, but encouraged, care staff were not paid to attend.” from the report
- 01What is the current level of statutory training compliance, and which training remains outstanding?
- 02What communication training was provided to the manager and staff after the inspection?
- 03Are staff now paid for attending shift handovers, as planned from 5 October 2020?
- 04How are night-time staffing levels covered when staff are off sick and agency cover is unavailable?
- 05Has the electronic care records system been fully transferred and is it accessible to staff on all floors?
This targeted inspection looked only at specific parts of Safe and Well-led, including infection control, staffing and management; it did not assess the full key questions. This explanation was written from the published report of 5 November 2020 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, September 2019
Rated Good overall; inspectors found safe, kind and personalised care, but staff training and supervision required improvement.
This was an unannounced planned inspection carried out over three days. Inspectors spoke with people living in the home, relatives, staff and other professionals. They reviewed care records, staff records, medicines information and quality checks.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were rated Good. Effective was rated Requires Improvement because staff training was not always up to date and supervision was not happening regularly.
Inspectors found people were generally safe, treated with dignity and supported according to their needs and preferences. The home had started action to improve training and supervision, but inspectors could not yet judge whether these changes would last.
Safe medicines systems
Medicines were given by trained staff whose competence had been checked. An electronic system and audits helped identify gaps or mistakes.
“The provider used an electronic medicines management system which helped to ensure medicines administration and recording were accurate, complete and up to date.” from the report
Kind and respectful care
Inspectors saw warm and caring interactions. Staff protected people's privacy and dignity and encouraged them to do things for themselves.
“We observed staff treating people with dignity and respect and encouraging them to be as independent as possible such as at mealtimes.” from the report
Personalised support
Care plans reflected people's needs, preferences and choices. The home provided activities on different floors and also offered one-to-one activities.
“People's needs were captured in comprehensive care plans which contained detailed information about how they wished to receive care and support.” from the report
Open management
The home had an open culture and systems for people, relatives and staff to give feedback. Inspectors found that some feedback led to changes.
“There was a warm and 'family' like culture within the service with a clear drive to provide high quality care.” from the report
Training was not up to date
needs fixingA six-month gap without a trainer meant much staff training was out of date. The home was booking missed mandatory and specialist training, but this would take time.
“Staff's training was not always up to date to ensure their knowledge and skills remained current.” from the report
Supervision was inconsistent
needs fixingStaff supervision was not regular or in line with the home's policy, and some sessions covered very little. Plans had been made, but inspectors had not yet seen evidence of sustained improvement.
“Staff supervisions were not regular or in line with the providers policy and some of the ones we did look at covered very little.” from the report
One person's restrictions
needs fixingInspectors found that one person's support arrangements could be overly restrictive. Changes were being made to avoid unnecessary restrictions.
“We found some of their support arrangements could be overly restrictive and changes were being made to avoid unnecessary restrictions.” from the report
- 01What proportion of staff training is now up to date, including specialist training?
- 02How often do staff receive supervision, and how do you check that it is regular and useful?
- 03What changes were made to the overly restrictive support arrangements, and how are these reviewed?
- 04How do you check current staffing levels when people and relatives report mixed views?
- 05How can residents and relatives raise concerns, and what recent changes have been made in response?
This was an unannounced planned inspection covering the premises and care provided, and it assessed all five key questions. This explanation was written from the published report of 10 September 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 Lodge Care Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- November 2020Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2019Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Outstanding
- November 2014
Registered with the Care Quality Commission on 13 November 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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