Archived: Lavender House

Updated 15 December 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

This inspection was carried out by three inspectors including one medicines inspector. An Expert by Experience supported the inspection by making phone calls to relatives. 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 is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Lavender House 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 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 a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the 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 spoke with commissioners and the local safeguarding team for any recent feedback of the service.

We used information gathered as part of monitoring activity that took place on 02 February 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people and 6 staff members including carers and the registered manager. We reviewed documentation relating to health and safety, staff recruitment and the maintenance of the property. We reviewed 5 people’s documents relating to their care. We reviewed documentation relating to the management of medicines, including the administration records for 10 people. We looked around the home to check whether the premises and equipment were suitably maintained and observed interactions between people who lived at the home and staff.

We spoke with the local fire service, local authority safeguarding team and the local infection control team during the inspection to ensure the registered manager had the correct support and advice.

After the inspection

We liaised with the local authority to share our inspection findings.

Updated 15 December 2022

About the service

Lavender House is a residential care home providing personal care to up to 32 people. The service provides support to older people. At the time of our inspection there were ten people using the service. Lavender House accommodates people in one adapted building over two floors.

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

The service was not well-led. The provider had failed to take action to improve or assess the safety of the service. Assurance systems to monitor risk and quality were not effective. Audits did not always identify issues and where issues had been identified these had not always been acted upon in a consistent and timely manner. Good practice guidance was not always considered and implemented.

The service was not safe. Routine servicing of equipment had not been completed. Staff did not always follow best practice to prevent and control the spread of infections. This put people at risk of harm. We could not be assured medicines were managed safely. Stock counts for people’s medicines were incorrect and best practice guidance had not always been followed. People and their relatives felt the service was clean but not always well maintained.

There were enough staff to meet people’s needs and staff had been recruited safely. Staff we spoke with were knowledgeable of people’s needs, risks and safeguarding systems. Staff told us they liked working at Lavender House and the registered manager was approachable.

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.

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 3 April 2019) and there were breaches of regulation. 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 improvements had not been made and the provider was still in breach of regulation.

This service has been rated requires improvement or inadequate for the last four 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.

Enforcement and Recommendations

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 identified breaches in relation to the management of risk, management of medicines and good governance at this inspection.

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 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.