Background to this inspection
Updated
3 August 2022
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.
Inspection team
The inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Lavender House Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was not a registered manager in post. The manager had applied to CQC to register as manager of the service. The application was being processed at the time of this inspection.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since their registration with CQC. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.
During the inspection
Inspection activity started on 30 May and ended on 22 June 2022. We visited the service location on 30 May and 14 June. We spoke to 11 people and relatives about their experience of the care provided. We spoke to the provider, the manager and seven members of staff. We reviewed a range of documents which related to the running of the service. These included five people’s care plans, risk assessments, medicines administration records, staff recruitment files, policies, audits, maintenance certificates and quality assurance records.
Updated
3 August 2022
About the service
Lavender House Care Home is a residential care home providing personal care to up to 22 people. The service provides support to older people, some of whom were living with dementia. At the time of our inspection there were 17 people using the service. The accommodation is spread over two floors, accessible via the stairs or stairlift. There is a secure garden which people can access.
People’s experience of using this service and what we found
Some aspects of the safety of the service required improvement. The arrangements for the management of medicines did not reflect best practice. Some records related to fire safety had not been completed consistently and not all mobility equipment was in good working order.
The leadership and governance of the home required improvement. This included work to ensure audits were effective in promoting improvement and identifying risks. The manager had applied to CQC to become the registered manager. They have acted upon feedback from this inspection and were putting plans in place to address the issues identified.
The provider did not ensure people’s needs were always fully assessed. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Some staff required training updates and aspects of the home’s decoration needed updating.
People and relatives told us that staff were kind and caring. They felt they were treated with dignity and respect and consulted about decisions around their care. People gave us positive feedback around the quality and choice of food available.
People’s care plans reflected their preferences around their personal care. People and relatives gave mixed feedback around the quality of activities and meaningful occupation people were supported to access. There were appropriate systems in place to respond to complaints.
For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk
Last rating and update
The last rating for the service under the previous provider was good, published on 25 July 2018.
Why we inspected
This service had not been inspected since the new provider took over and we wanted to check people were receiving safe care and support
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have found breaches in relation to medicines management and governance at this inspection.
Please see the action we have told the provider to take at the end of the full version of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.