CQC report explained · a nursing home
What the CQC found at Lavender Lodge Nursing 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, August 2022
Lavender Lodge Nursing Home is rated Good overall, but inspectors found safety improvements were needed with creams, recruitment checks and face masks.
Inspectors visited the home without notice on 26 July 2022. They spoke with people, relatives and staff, observed care, and reviewed records and information from other agencies.
The home was rated Good overall. Caring and well-led were rated Good. People were treated kindly, involved in decisions and supported by staff who promoted their dignity, privacy and independence.
Safe was rated Requires Improvement. Inspectors found problems with storing and recording skin creams, incomplete checks before some staff started work, and some staff not wearing face masks correctly. They also found enough staff, a clean environment and systems for managing risks and safeguarding people.
Kind relationships
People and relatives described positive relationships with staff. Inspectors saw staff talking and joking with people and supporting their dignity.
“People and relatives told us they had positive relationships with staff. We observed people enjoyed jokes and conversations with staff.” from the report
Enough staff
Inspectors found enough staff to respond to people's needs and promote their safety. Rotas included a suitable mix of staff roles and skills.
“There were enough staff deployed for people to receive safe care.” from the report
Risk management
Risks linked to people's health, care needs and the environment were identified and reviewed. Staff responded quickly when people needed help to move safely.
“Risks associated with people's health and care needs were identified and kept under regular review.” from the report
Involvement in care
People and families said they were listened to and involved in care decisions. Care plans recorded people's views and the involvement of others.
“People and families told us they felt listened to and involved in their care decisions.” from the report
Skin cream storage and records
seriousSome skin creams were not stored securely, and labels could not always be read clearly. Records for admitting topical skin creams were incomplete.
“Creams for people's skin were not stored securely and it was not always possible to read the labels to confirm who the cream had been prescribed for.” from the report
Recruitment checks
seriousSome required checks had not been completed before care staff started work. Gaps in employment history and missing alternative character checks were not always recorded.
“Required pre-employment checks on staff had not always been completed fully.” from the report
Face mask use
needs fixingSome staff were seen not wearing face masks correctly. Managers said they would carry out further checks on staff practice.
“We were not fully assured that the provider was always using personal protective equipment (PPE) effectively and safely.” from the report
Privacy incident
minorInspectors were told about a recent incident that affected a person's privacy and their family's privacy. The manager said an apology had been made and action taken to prevent it happening again.
“A recent incident had infringed on the privacy of a person and their family.” from the report
- 01How are skin creams now stored securely, and how do you check that labels and administration records are complete and readable?
- 02What checks are now completed before a new care worker starts, including gaps in employment history and alternative character checks?
- 03How do you check that staff wear face masks correctly and consistently when required?
- 04What action was taken after the privacy incident, and how do you check that privacy is protected now?
- 05What is the timetable for replacing shared bedrooms with single occupancy rooms and completing bedroom refurbishment?
The report gives findings and ratings for Safe, Caring and Well-led, says ratings for key questions not inspected may carry over from the previous inspection, and does not show ratings for Effective or Responsive. This explanation was written from the published report of 23 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.
What inspectors found, June 2019
Rated Good; inspectors found safe, kind and personalised care, with some further improvements needed to medicines storage, activities and the environment.
This was an unannounced comprehensive inspection on 23 April 2019. Inspectors spoke with people living at the home, relatives and staff. They observed care and checked records, medicines, staffing, accidents, incidents and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that improvements had been made since the previous inspection, including safer medicines management, clearer medical records, better risk management and stronger audits.
There were still some areas to improve. Medicines storage could become unsafe if temperatures rose, some parts of the environment were not yet fully suitable for people living with dementia, and people wanted more activities. The manager said action was planned or under way.
Safe staffing
People and relatives said the home was well staffed. Inspectors saw staff present in communal areas and supporting people elsewhere when needed.
“During out inspection visit we saw a continual staff presence in communal areas and staff assisting people in other areas as necessary.” from the report
Kind care
People and relatives described staff as caring and kind. Inspectors saw staff reassuring a distressed person calmly and respectfully.
“People and relatives said the managers and staff were caring and kind.” from the report
Personalised support
Care plans included people's life histories, interests, communication needs and cultural backgrounds. Staff used this information to provide individual support.
“People received personalised care that met their needs. Care plans were up-to-date and regularly reviewed.” from the report
Improved oversight
The home had introduced a more effective audit system. Audits identified problems and were used to track improvements and share learning with staff.
“The home had a new audit system which was comprehensive and effective.” from the report
Medicines temperature
needs fixingSome medicines storage areas were close to the maximum room temperature. The home needed a safer, more permanent way to keep them within range if temperatures rose.
“some storage areas for medicines that needed to be stored at 'room temperature' (15 to 25C) were close to 25C.” from the report
Medicines left in bedrooms
needs fixingTopical creams in people's bedrooms had not been risk assessed. An undated sharps box was also noted, although the manager said these issues would be addressed.
“Topical creams left in people's bedroom needed risk assessing as people can mistake them for other items, for example toothpaste.” from the report
More activities needed
minorPeople and relatives wanted more activities. Care workers provided some activities around their care duties, and the manager was recruiting an activities coordinator.
“People and relatives said they would like more activities at the home.” from the report
Dementia-friendly environment
minorSome improvements had been made to the building, but bedroom doors did not have personalised items to help people recognise their own rooms. Further refurbishment was planned.
“However, there was no personalised information, for example pictures or other items, on the doors to make it easier for people to identify their own rooms.” from the report
Staff approach
minorInspectors found staff were attentive and kind, but some could use a warmer and less task-focused approach.
“some could have been warmer in their approach to people and less direct and task-based.” from the report
- 01How do you now keep medicines safely within the required temperature range during hot weather?
- 02Have the topical creams in bedrooms been risk assessed, and has the undated sharps box been dealt with?
- 03Has an activities coordinator been appointed, and what regular activities are now available?
- 04What changes have been made to help people living with dementia recognise their bedrooms and move around the home?
- 05How are staff supported to use a warmer, less task-focused approach when speaking with people?
This was an unannounced comprehensive inspection covering the home, the care provided and all five CQC questions. This explanation was written from the published report of 1 June 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 Nursing Home
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- August 2022Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2019Goodup from Requires improvementSafe: GoodCaring: GoodWell-led: Good
- October 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 19 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
78 live-in carers within about an hour of Derby
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 62 can care for a couple. 12 years' experience on average.
“We particularly appreciate the companionship Dawn gives in the evenings when she plays cards and Scrabble with my mother.”
“Rachel is a quietly spoken, extremely caring person and looked after Val very well.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.