CQC report explained · a residential care home
What the CQC found at Lavender Lodge
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 within recommended temperature limits. A person at risk of choking was not always given the required diet and supervision.
- Effective?
- Requires improvement
- Care and support did not always achieve consistent good outcomes. The building and garden were not fully adapted for people living with dementia, and people were not always given clear food choices.
- Caring?
- Requires improvement
- This question was not inspected during this focused inspection. Its rating was not given in this report.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its rating was not given in this report.
- Well-led?
- Requires improvement
- Management checks did not identify problems with medicines, risks and care records. Formal feedback from people and relatives had not been sought.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found medicines and risk management were not always safe, and oversight of care needed to improve.
This was an unannounced, focused inspection on 13 June 2023. Inspectors checked Safe, Effective and Well-led. They spoke with people, relatives and staff, observed care, and reviewed care plans, medicines records, staff files and management records.
The home remained rated Requires Improvement overall. Medicines were not always stored at the right temperatures. One person at risk of choking was not given the recorded diet and supervision needed. Some risks and care plans were not kept up to date.
There were also concerns about task-based care, limited activities, the dementia environment and the quality of management checks. People said they felt safe, staffing levels were sufficient, medicines were usually given on time, and people had access to food and healthcare support.
The provider remained in breach of Regulation 12 on safe care and treatment and Regulation 17 on good governance. This was the third consecutive inspection with a Requires Improvement rating. The regulator said it would monitor progress with the provider and local authority.
People felt safe
People and relatives said they felt safe and cared for. Staff had safeguarding training and knew how to report concerns.
“People were protected from the risk of abuse or harm.” from the report
Enough staff
Inspectors found staffing levels were sufficient and people were attended to promptly. Recruitment checks had also been completed.
“Staffing levels were sufficient to meet people's care and support needs.” from the report
Healthcare support
People had contact with healthcare professionals, including regular visits from primary care staff and referrals to specialist teams when needed.
“A GP or practice nurse had weekly contact with the home and undertook a face to face weekly visit.” from the report
Infection control
Inspectors were assured that infection prevention measures, protective equipment and outbreak arrangements were in place.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Medicine storage
seriousTemperature checks did not always lead to action when medicines were stored outside the recommended limits. The medicines trolley was above the recommended maximum when checked.
“The temperature within the medicines trolley was not monitored.” from the report
Choking risk
seriousA person identified as being at risk of choking was given food that did not match the recorded guidance and was not continuously supervised.
“This put the person at risk of choking based on the risk assessments and information recorded in their care plan.” from the report
Care was task-based
needs fixingInspectors found that care was focused on completing tasks rather than making care personal and meaningful. Activities were not available every day.
“The home did not always provide a positive culture for people; the care provided was task-orientated.” from the report
Dementia environment
needs fixingThe building had not been specifically adapted for people living with dementia. The garden was unkempt and the room called the sensory room did not provide sensory experiences.
“The premises had not been specifically adapted to meet the needs of people living with dementia.” from the report
- 01How are medicine temperatures now checked in the refrigerator, medicines room and trolley, and what happens when a reading is outside the recommended range?
- 02How are choking risks and special diets communicated to cooks and care staff at every meal?
- 03How are care plans and emergency evacuation plans reviewed when a person's needs change?
- 04What daily activities are now available for people living with dementia, including access to the garden and sensory experiences?
- 05How do you collect and act on regular feedback from people and their relatives?
This was an unannounced focused inspection of Safe, Effective and Well-led; the other key questions were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 2 August 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, July 2022
Rated Requires Improvement; inspectors found kind care and enough staff, but unsafe medicines, risks and weak management systems.
This was an unannounced focused inspection on 17 February 2022. One inspector spoke with people, a relative, managers and care staff. They observed care and reviewed care plans, medicine records, staff files and management records.
The home remained rated Requires Improvement overall. Safe, caring and well-led were also rated Requires Improvement. Medicines were not always stored, recorded or disposed of safely. Inspectors also found risks from a hot radiator, cluttered areas and unsecured bathroom items.
Staff were caring and respectful, and there were enough staff to meet people's needs. Some infection control improvements had been made, but cleaning was not consistently thorough. Care plans lacked important details, and audits and feedback systems had not reliably identified problems.
The inspection found breaches of three regulations. The provider was asked for an action plan, and CQC said it would monitor progress and consider further action if needed.
Kind and respectful staff
Staff were observed treating people with dignity and respect. They asked permission before providing care and adapted their approach when someone did not want help.
“We observed staff asking people for permission before intervening with any aspect of their care.” from the report
People felt safe
People told inspectors they felt safe at the home. Staff had safeguarding training and knew how to report concerns.
“One person told us, "I like it here and I feel safe. I've got someone I can speak to and ask".” from the report
Enough staff
Inspectors found there were sufficient staff to support people safely. Recruitment checks were completed for new staff.
“There were sufficient staff to support people safely.” from the report
Some management improvements
Since the previous inspection, staff had become more attentive to people's needs and confidential information had been removed from bedroom doors.
“At this inspection, actions had been taken and improvements were made. Staff were attentive and sensitive to people's needs.” from the report
Medicine safety
seriousSome medicines did not have opening dates, medicines for people who had died were still stored, and one medicine was missing from the register. This created a risk of people receiving out-of-date medicines or medicines that were not properly accounted for.
“Medicines were not always managed safely.” from the report
Other safety risks
seriousA very hot radiator was placed next to a person without a risk assessment. A cluttered sensory room reduced people's access and could have caused trips, while bathroom products were not securely stored.
“The provider had failed to ensure medicines and risks to people were managed safely.” from the report
Cleaning standards
needs fixingThere was no dedicated housekeeping worker at the inspection. Inspectors found that cleaning was not consistently thorough, including a toilet that needed a thorough clean.
“We observed cleaning was not undertaken to a high standard, for example, a toilet pan in a bathroom next to the dining area was in need of a thorough clean.” from the report
Incomplete care plans
needs fixingSome care plans did not include important information about people's needs, risks, history, preferences or how staff should support them.
“Information within care plans for people who had recently moved into the home lacked detail.” from the report
Weak checks and feedback
needs fixingAudits had not identified the medicine problems, and the home had not formally asked people, relatives or staff for feedback. This limited the provider's ability to spot and improve problems.
“Systems were not sufficiently robust to monitor the care delivered or the service overall.” from the report
Incorrect rating information
needs fixingThe latest rating was not displayed at the home. The website presented an older Good rating in a way inspectors said was misleading and inaccurate.
“This is misleading and inaccurate information.” from the report
- 01What has been done to ensure every medicine has the correct opening date, secure storage and disposal record?
- 02How are you now checking for risks such as hot radiators, cluttered rooms and unsecured bathroom products?
- 03Have the care plans been updated with each person's health needs, risks, preferences and support instructions?
- 04What regular audits are now in place, and how will you show that they identify and fix problems?
- 05How are you collecting feedback from residents, relatives and staff, and what changes have resulted from it?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 2 July 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 Lodge
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2018GoodSafe: GoodEffective: GoodCaring: GoodWell-led: Good
- August 2015
Registered with the Care Quality Commission on 18 August 2015.
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 £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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