CQC report explained · a nursing home
What the CQC found at Lavender Oaks Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risk records and medicine records had improved, although some expired medicines and out-of-date equipment were found and removed.
- Effective?
- Good
- This area was not covered by this focused inspection, so no rating was given in this report.
- Caring?
- Good
- This area was not covered by this focused inspection, so no rating was given in this report.
- Responsive?
- Good
- People's care was reviewed and activities and communication were adapted to individual needs. Some records did not contain enough information about hobbies, interests, spiritual needs and end-of-life wishes.
- Well-led?
- Good
- The provider had improved its checks, staff training and systems for learning from problems. There was no registered manager in post at the time of the inspection, although a new manager had been recruited and was beginning the registration process.
What inspectors found, July 2021
Rated Good; inspectors found safe, kind care, but some end-of-life records and out-of-date items needed attention.
This was an unannounced focused inspection on 15 June 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, accident and quality records. Part of the inspection was completed remotely.
The home was rated Good for Safe, Responsive and Well-led. Inspectors found people felt safe, staff were caring, medicines were generally managed safely, infection control measures were in place, and there were enough staff to meet people's needs.
Some records did not fully explain people's hobbies, spiritual needs or end-of-life wishes. Inspectors also found some expired medicines and out-of-date equipment, which were removed immediately. The home had improved since the previous inspection and was no longer breaching regulations.
This was not a full review of all five areas. The Effective and Caring areas were not inspected during this visit, and their previous ratings were used when calculating the overall rating.
Improved risk records
Care records gave staff more detailed information about people's risks and how to manage them. Staff had also received training in preventing and managing pressure ulcers.
“People's records had been reviewed and updated to make sure they gave staff the information they needed to identify and manage people's individual risks.” from the report
Safe medicine administration
Qualified staff administered medicines, with competency checks and refresher training. Medicine records showed people received their medicines when needed.
“Only qualified staff administered people's medicine. Regular competency checks and refresher training made sure staff continued to have the skills and knowledge to keep people safe.” from the report
Infection control
Inspectors were assured that the home was following measures covering PPE, testing, visits, cleaning and the prevention and management of outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Activities and relationships
The home adapted activities during the pandemic and supported people to keep in touch with relatives. Activities included outdoor entertainment, games, nail painting and minibus trips.
“People were encouraged to engage in various activities and the activities coordinator was keen to broaden the choice available to people as COVID-19 lockdown restrictions eased.” from the report
Listening to complaints
People and relatives said they felt listened to when they complained. The provider had systems to record and monitor complaints.
“People and their relatives told us when they had made a complaint they felt listened to and their concerns had been addressed.” from the report
Expired medicines and equipment
needs fixingInspectors found some out-of-date specimen tubes and expired over-the-counter remedies. The manager destroyed the medicines immediately and said all medical equipment would be checked.
“However, when we looked at some of the equipment used, for example specimen tubes, we found these were out of date and some homely remedies, or medicines that could be purchased over the counter at a pharmacy had expired.” from the report
Incomplete end-of-life information
needs fixingRecords did not consistently set out people's end-of-life wishes or show their involvement and the involvement of relatives and health professionals. The provider said it was improving this process.
“Some people had clear involvement in developing their end of life care plans with evidence of family and healthcare professional's involvement whereas others had little or no detail.” from the report
Missing lifestyle details
minorSome care records did not include enough information about people's hobbies, interests and spiritual needs.
“However, some records lacked information about people's hobbies, interests and spiritual needs.” from the report
No registered manager at the visit
minorThe home did not have a registered manager when inspectors visited. A new manager had been recruited afterwards and had started the registration process.
“At the time of our inspection the service did not have a registered manager in post.” from the report
- 01How do you now record and review each person's end-of-life wishes, and how are relatives and health professionals involved?
- 02What checks are now in place to make sure medicines, specimen tubes and other medical equipment have not expired?
- 03Has the new manager completed the CQC registration process, and who is responsible for the home until that is complete?
- 04How do you record each person's hobbies, interests and spiritual needs in their care plan?
- 05How quickly will you respond if a family raises a complaint or concern?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried over when calculating the overall rating. This explanation was written from the published report of 22 July 2021 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, March 2021
Inspected but not rated; inspectors were assured about most infection controls, but social distancing was not fully assured.
This was an unannounced, targeted inspection on 26 January 2021. It looked at infection prevention and control during the coronavirus pandemic, following information of concern.
Inspectors were assured about visitor screening, personal protective equipment, testing, cleaning, admissions and managing outbreaks. People who had COVID-19 or symptoms were isolated, and the home used zones to reduce infection risks.
Inspectors were only somewhat assured about shielding and social distancing. Staff said it was difficult to support some people to stay apart when they did not understand the risks or refused to isolate.
The service was inspected but not rated. The previous Safe rating was Requires Improvement, but CQC did not review that rating during this inspection.
Infection control
Inspectors found that PPE was available and used safely. Staff had been trained in current infection control guidance.
“We were assured that the provider was using PPE effectively and safely.” from the report
Cleaning
The home used enhanced cleaning, including daily cleaning and extra cleaning of frequently touched surfaces.
“Enhanced cleaning took place with daily cleaning by the dedicated housekeeping team using recommended chlorine-based cleaning products.” from the report
Family contact
The home used screened visiting areas, outdoor visits and other ways to help people keep in touch with relatives when visits were restricted.
“When relatives were able to visit, the service had designated screened areas to allow visits to take place safely.” from the report
Managing outbreaks
People with COVID-19 or symptoms were isolated, and the home used zones to help limit the spread of infection.
“The provider had zoned each area of the home and ensured people and staff stayed within their zone to help stop the spread of infection.” from the report
Social distancing
needs fixingInspectors were only somewhat assured that shielding and social distancing rules were being met. Staff found it difficult to support some people who did not understand the risks or refused to isolate.
“When people did not understand the risks of infection or refused to isolate staff told us they found it hard to support people to remain socially distanced from others.” from the report
- 01How do you support people who do not understand infection risks or refuse to isolate?
- 02How are people kept safely apart when there is an infection risk?
- 03How do you screen visitors and provide PPE during visits?
- 04How often are frequently touched surfaces cleaned, and which cleaning products are used?
- 05How do you use zoning, testing and isolation if there is a new infection or outbreak?
This was a targeted, unannounced inspection of infection prevention and control only; the previous Safe rating was Requires Improvement and was not reviewed, while the other key questions were not assessed. This explanation was written from the published report of 4 March 2021 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 Oaks Care Home
4 rated inspections over 3 years: the service has held its Good rating throughout.
- July 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not rated
- May 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- November 2018GoodSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- October 2017
Registered with the Care Quality Commission on 27 October 2017.
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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