Lavender Lodge

Updated 2 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by 2 inspectors.

Service and service type

Lavender Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Lavender Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people and 2 relatives about their experience of the service. We spoke with the registered manager, a registered manager from one of the provider’s other homes who was present at the time of the inspection, the cook, and 3 care staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We reviewed a range of records including 3 care plans and multiple medication records. We looked at 2 staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 2 August 2023

Lavender Lodge is a residential care home providing accommodation and personal care to up to 20 people. The service provides support to older people and those living with dementia. At the time of our inspection there were 20 people using the service.

People’s experience of using this service and what we found

People’s prescribed medicines had not always been stored within recommended temperature limits, in the refrigerator, or in the medicines trolley. Risks to people were not always safely managed to prevent them from harm.

People did not always receive personalised care that met their individualised needs; care was task-based. Information within some care plans was not always reflective of people’s changing needs. The premises had not been adapted to provide a dementia-friendly environment. Auditing systems were not sufficiently robust to identify the issues found at this inspection.

People’s consent to care and support was gained in line with the requirements of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People felt safe living at Lavender Lodge. A relative said, “It’s a nice home, nicely run and the home feels caring. The manager is lovely and chats with people. My mother is well looked after, she’s smiling and happy. I get the impression that staff know people well”. There were sufficient staff on duty to ensure people’s needs were met promptly.

People were supported to have a nutritious diet and healthy lifestyle. They had access to healthcare professionals when this was required.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 2 July 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We carried out an unannounced focused inspection of this service on 17 February 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe, Effective and Well-led.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lavender Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to medicines management, how people’s risks were managed, and the governance of the service.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.