CQC report explained · a nursing home
What the CQC found at Lavender Villa
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were generally enough staff, suitable recruitment checks and risk assessments. However, medicines records did not always give enough detail for covert or occasional medicines, so the provider was asked to review best practice.
- Effective?
- Good
- People's needs were assessed, staff received relevant training and people could access healthcare and suitable food. Care plan quality varied, with some records less detailed or harder to follow.
- Caring?
- Good
- People and relatives described staff as kind and respectful. Inspectors saw staff protecting privacy, promoting independence and involving people in decisions about their care.
- Responsive?
- Good
- People were involved in care planning and received personalised support, activities and help to maintain relationships. Some care plans were more detailed and easier to follow than others.
- Well-led?
- Requires improvement
- The provider was restructuring management and developing electronic care records. However, checks and audits were not robust enough to identify and address all shortfalls, and the home remained in breach of Regulation 17.
What inspectors found, November 2021
Lavender Villa is rated Requires Improvement; inspectors found kind, effective and responsive care, but medicines records and quality checks were not always reliable.
Inspectors visited unannounced on 28 September 2021. They spoke with people, relatives and staff, observed care, checked the home and reviewed care, medicines and management records. They also checked infection prevention and control arrangements.
People generally felt safe and said staff were kind, caring and supportive. There were enough staff in most circumstances, staff were trained, people received help with meals and healthcare, and activities were available. However, some medicines records did not explain clearly enough how occasional or covert medicines should be given and recorded.
The home had improved since the previous inspection, and Effective, Caring and Responsive were rated Good. Safe remained Requires Improvement, while Well-led improved from Inadequate to Requires Improvement. The home was still breaching Regulation 17 because its checks and audits had not reliably found problems with records and care systems.
Kind and respectful staff
People and relatives spoke positively about the care. Staff knew people well and respected their privacy, dignity and independence.
“Staff were kind and caring and knew people well.” from the report
Activities and community links
People could take part in activities inside the home and in the community. Staff also supported cultural and religious interests.
“People were supported to access a range of activities both within the service and in the community.” from the report
Choice and independence
People were encouraged to make decisions about daily life and to do tasks for themselves where possible. The home followed the least restrictive approach described in the report.
“People were supported to have maximum choice and control of their lives” from the report
Improved care outcomes
Effective, Caring and Responsive all improved from Requires Improvement to Good since the previous inspection.
“At this inspection this key question has now improved to Good.” from the report
Medicines records
needs fixingRecords did not always explain safely and clearly how covert medicines and medicines given occasionally should be administered, monitored or recorded.
“Records did not always contain enough detail about how to support people with covert medicines.” from the report
Weak quality checks
seriousThe home's systems for checking care quality and safety did not find some of the problems identified by inspectors. This placed people at risk of harm, although inspectors found no evidence that anyone had been harmed.
“Systems to assess, monitor and improve the quality and safety of the service and mitigate risk were not always effective in identifying and addressing shortfalls.” from the report
Uneven care records
needs fixingSome care plans were detailed and personalised, but others had less information or were difficult to follow because of handwritten changes.
“Some people had detailed personalised plans and others contained less detail or were difficult to follow due to handwritten amendments.” from the report
Management changes
needs fixingThe management team was being restructured and recruitment was still taking place. Some audits did not cover all relevant areas.
“The service was going through the process of a management restructure at the time of this inspection.” from the report
Some areas needed updating
minorAlthough the home was described as tidy and spacious, some areas were grubby and needed updated decoration.
“Some areas of the service were grubby and in need of updated decor.” from the report
- 01How are covert medicines now assessed, authorised, administered and monitored?
- 02How do you check that records for occasional medicines and creams contain clear instructions and are completed consistently?
- 03Is the new electronic care record system now fully in use, and how do you check that care plans remain personalised and complete?
- 04What changes have been made to the management team since the inspection, and who is now responsible for each regulated activity?
- 05What action has been completed in response to the Regulation 17 breach, and what evidence can you show that your audits now find problems promptly?
This was an unannounced planned inspection covering all five key questions, including infection prevention and control; it followed the previous Requires Improvement rating published on 30 April 2020. This explanation was written from the published report of 6 November 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, April 2020
Rated Requires Improvement; inspectors found safety and care shortfalls, with leadership rated Inadequate.
The unannounced inspection took place on 25 and 26 February 2020. Inspectors spoke with people, family members, staff and managers. They observed care and reviewed care plans, medicines records, recruitment files and management records.
Inspectors found risks in safe care, staff training, recruitment and record keeping. Some staff used unsafe moving and handling methods. Previous safeguarding incidents had not always led to effective action. Care was sometimes task-led, and people's individual preferences and needs were not always followed.
People often described staff as kind, and medicines, food, infection control and access to healthcare were generally managed well. However, weak management checks had not found or fixed important problems. The home was rated Requires Improvement overall, with Well-led rated Inadequate.
The provider took prompt action after the inspection and gave CQC further information. CQC planned to request an action plan, work with the local authority and return to check progress.
Kind interactions
People spoke positively about staff, and inspectors saw kind and compassionate support when staff interacted with people.
“When staff did interact with people, they were kind, caring and compassionate.” from the report
Food and nutrition
Care plans recorded dietary needs, and staff supported people at mealtimes. Inspectors found protection against risks such as dehydration, weight loss and choking.
“People were protected from risks associated with poor nutrition, hydration and swallowing difficulties; such as weight loss, dehydration and choking risks.” from the report
Healthcare access
People received support from healthcare professionals and were helped to attend appointments when needed.
“The service supported people to access health appointments, such as hospital, when needed.” from the report
Medicines management
Nurses stored and managed medicines safely. Some stock-count recording errors were found in the newly introduced electronic system, but inspectors found no evidence that medicines were given at the wrong times.
“Medicines were stored and managed safely by suitably trained and qualified nurses.” from the report
Clean environment
The home was generally clean and hygienic, with staff using protective equipment and disposing of clinical waste correctly.
“The control and prevention of infection was generally well managed.” from the report
Unsafe care practices
seriousSome staff had not been trained for people's specific risks, and inspectors saw moving and handling being done incorrectly. This could have caused avoidable harm.
“Staff were observed not always following safe moving and handling procedures which could place people at avoidable harm.” from the report
Safeguarding follow-up
seriousThe home had not always taken strong enough action after earlier safeguarding incidents to prevent them happening again.
“Robust action had not always been taken following previous safeguarding incidents to ensure they did not happen again and to keep people safe from harm.” from the report
Poor care records
needs fixingSome records were inconsistent, out of date or hard to read. This made it difficult for staff to find reliable information about people's needs.
“A lack of robust record keeping placed people at risk of receiving ineffective care and support to meet their needs.” from the report
Personalised care
seriousCare did not always reflect people's preferences or legal conditions. One person told inspectors they sometimes could not get help to reach the toilet at night.
“[Staff] don't always come when I ask for help. At night sometimes I have to wet myself because I need the toilet and can't get there on my own.” from the report
Weak leadership
seriousManagement checks did not identify the problems found, and senior management oversight was limited. Staff also had few opportunities to share their views.
“The provider's governance systems had failed to identify the concerns highlighted on this inspection such as people's safety, staff recruitment, lack of person-centred care planning and delivery and poor record keeping.” from the report
Dignity and meaningful time
needs fixingPeople were sometimes left without support or meaningful interaction. Inspectors also found language about distressed behaviour that was not respectful.
“We observed long periods of time on both days of inspection, where people were left unsupported and with limited interaction from staff.” from the report
- 01What specific changes have been made to moving and handling training, and how do you check staff follow the correct procedures?
- 02How have you strengthened recruitment checks, including verifying references and assessing applicants' previous history?
- 03What action was taken after the safeguarding incidents mentioned in the report, and how do you know the risk has not returned?
- 04How do you ensure care plans contain current, readable information about each person's needs, preferences, communication and life history?
- 05How will you provide enough experienced staff and effective daily management oversight on every shift?
This was an unannounced inspection covering all five key questions, with the report noting it was the first inspection since the service re-registered at this address. This explanation was written from the published report of 30 April 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.
Every inspection of Lavender Villa
3 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- November 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- December 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2019
Registered with the Care Quality Commission on 15 April 2019.
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
84 live-in carers within about an hour of Cheshire West and Chester
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 £980 to £1,260 a week. 76 can care for a couple. 10 years' experience on average.
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
“It was clear that she genuinely cared and her warm approach really helped put our minds at ease.”
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.