We carried out a review of the data available to us about Lavender Oaks Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Lavender Oaks Care Home, you can give feedback on this service.
Lavender Oaks Care Home is a residential care home providing personal and nursing care to 43 people at the time of the inspection. The service can support up to 75 people within four suites in one purpose-built building.
People’s experience of using this service and what we found
People told us they felt safe and that, they were looked after by caring staff. Systems remained in place to protect people from abuse and staff had been trained in safeguarding adults and knew how to report concerns. Improvements had been made to people’s records. This meant there was more detailed information for staff to understand people’s risks and what staff needed to do to reduce these. Medicine records were accurate and showed people received their medicine when they needed it. The provider recorded and monitored accidents and incidents in order to identify trends and had systems in place to make sure lessons were learnt when things when wrong. The service was clean and staff followed government guidance around COVID-19 to help stop the risk of infection. There were enough staff working at the service to meet people's needs.
People’s care and support was assessed when they first started to use the service. People’s care was regularly reviewed and the provider was making changes to make sure staff knew exactly how people wanted to be supported based on their individual needs during their time at the service and when they required end of life care. Staff helped people maintain relationships and had adapted activities during the pandemic to reduce the feeling of isolation. Systems were in place to record and monitor complaints received.
Improvements had been made to the way the provider monitored the quality of care people received at the service. Staff had received additional support and learning and new initiatives had been introduced to help keep people safe. People told us the manager listened to them and made changes according to their preferences.
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 20 May 2020) and there was one breach 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 been made and the provider was no longer in breach of regulations.
Why we inspected
We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. We had also received concerns about end of life care and we wanted to inspect and examine risks in this area. We found no evidence during this inspection that people were at risk of harm from this concern. This report only covers our findings in relation to the key questions safe, responsive and well-led.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lavender Oaks Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
People's experience of using this service and what we found
People were supported to maintain relationships with people who were important to them. When relatives were able to visit, the service had designated screened areas to allow visits to take place safely. The garden and outside areas were utilised when the weather allowed. When visits were restricted staff used alternative methods to help people maintain social contact with their family.
All visitors to the service were screened for symptoms of COVID-19 before being allowed to enter the home. Personal Protective Equipment (PPE) was available for visitors to wear should they need it.
People who had tested positive for COVID-19 or were showing symptoms were isolated in their rooms. 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. People who did not wish to stay in their rooms were encouraged by staff to remain socially distanced from others. The provider had detailed risk assessments in place to help staff manage the risk of infection.
Staff had been trained in current infection prevention and control (IPC) guidance and the use of PPE. Staff were wearing their PPE and explained in detail the donning and doffing process. Enhanced cleaning took place with daily cleaning by the dedicated housekeeping team using recommended chlorine-based cleaning products. During the day staff undertook additional cleaning of frequently touched surfaces using a neutral-based cleaning product.
Lavender Oaks Care Home is a residential care home providing personal and nursing care to 56 people at the time of the inspection. The service can support up to 75 people within four suites in one purpose-built building.
People’s experience of using this service and what we found
People did not always receive care and treatment that was safe, because there was not always sufficient information available to staff about how to manage people’s risk of developing pressure ulcers. For people who already had pressure ulcers, there was not enough information for staff to ensure the correct care and treatment to promote healing and prevent further damage. We also found there was not enough information about people’s medicines for staff to ensure people received “as required” medicines when needed, although other medicines were managed safely.
Other risks to people’s safety were assessed and managed safely, although in some cases detail was missing from people’s mobility assessments. Staff checked the premises and people's individual mobility equipment to ensure they were safe for people to use.
Although the provider had systems in place to monitor and improve the quality of the service, these required some improvement as they had not identified the issues we found around risk assessment and management.
The provider had systems to assess the staffing needs of the service, based on the level of support people required in different parts of the home. Although there were enough staff to care for people safely, there was still a need to further review how staff were deployed because a large proportion of falls happened when people were alone in their bedrooms.
There were effective systems in place to protect people from the risk of abuse and to control infection. Staff were recruited safely. When accidents and incidents happened, the provider had systems in place to learn from these and prevent things from going wrong again. They had completed a thorough analysis of falls to identify trends and took effective action in response to lower this risk.
People’s needs were assessed, and reassessed when needed, in line with guidance and best practice. Staff worked well with other agencies to do this. Staff received the training and support they needed to do their jobs well, although we did not find enough evidence to show nurses received regular supervision. We will check this again at our next inspection.
People received support to eat and drink enough to stay healthy, and to attend healthcare appointments when needed. The environment was suitably adapted to meet people’s needs.
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, relatives and staff had opportunities to feed back their opinions of the service. The registered manager understood their regulatory requirements and was open and honest with people when things went wrong. They listened to people’s views and acted on them as part of continually improving the service, and worked well in partnership with others.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 6 August 2019).
Why we inspected
The inspection was prompted in part due to concerns received about an increased number of falls leading to serious injuries; staffing levels; medicines management; management of people’s health conditions and continuing care when people returned to the home from hospital. A decision was made for us to inspect and examine those risks.
We undertook a focused inspection to review the Key Questions of Safe, Effective and Well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lavender Oaks Care Home on our website at www.cqc.org.uk.
Enforcement
We have identified a breach of the regulation in relation to safe care and treatment. This relates to management of risk around pressure ulcers. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Lavender Oaks Care Home is a ‘care home’ providing personal and nursing care to people, some of whom may be living with dementia, at the time of this inspection. The service can support up to 75 people. The care home accommodates 39 people in one purpose built building.
People’s experience of using this service and what we found
The risk that people might experience avoidable harm were reduced by the provider. People’s risks, including those associated with their healthcare needs, were assessed and plans were in place to mitigate them. Staff were trained to safeguard people and the provider followed clear safeguarding procedures.
People’s medicines were stored, administered, recorded and audited appropriately. Good hygiene practices meant people were protected from the risk and spread of infection. The service learned and improved following incidents were things had gone wrong.
The service continued to be well-led. Robust quality assurance processes were in place which identified shortfalls and drove improvements. People, relatives and staff were encouraged to share their views about care and support at the service. The provider continued to work collaboratively with other agencies and organisations to meet people’s needs.
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.
The last rating for this service was Good (published 15 November 2018).
Why we inspected
The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to a separate investigation. As a result, this inspection did not examine the circumstances of the incident. The inspection was also prompted in part due to safeguarding alerts and CQC notifications raised by the Home Manager about falls. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.
We found no evidence during this inspection that people were at risk of harm from this concern. The provider had taken action to mitigate the risks and this has been effective. Please see the Safe and Well-Led sections of this report.
We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.
The overall rating for the service has not changed from Good. This is based on the findings at this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lavender Oaks Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
This was the first inspection of regulated activity at Lavender Oaks Care Home since it registered with the Care Quality Commission in October 2017. Lavender Oaks Care Home is a ‘care home’. People in care homes receive accommodation, nursing and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide accommodation, nursing and personal care for up to 75 people. Since opening the service has taken a gradual approach to admissions. At the time of our inspection there were 26 people living in the service.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Staff were trained to protect people from mistreatment and the risks of avoidable harm. There were enough nursing and care staff to ensure care was delivered safely at all times. Staff were recruited using robust procedures. Infection control practices and food safety protocols were in place to prevent the risk or spread of infection. An extensive range of checks were undertaken on a frequent basis to ensure the safety of the care home environment.
People had detailed holistic assessments in place and their care was delivered by trained and supervised staff. People ate well and their nutritional needs and preferences were met. People consented to the support staff provided and staff delivered support in line with mental capacity legislation and guidance. The provider placed an emphasis on meeting people’s nutritional needs and preferences through a pleasurable social experience in attractive surrounds. The premises was purpose built with a high quality décor.
Staff were caring and kind to people and worked towards getting to know people well. People were supported to have their communication needs assessed and met. Staff treated people with dignity and respect and enabled people to maintain relationships with loved ones.
People’s support was delivered in line with detailed and regularly reviewed care plans which reflected their preferences and assessed needs. Staff supported people to engage in a wide range of activities. Measures were in place to protect those who chose not to join in group activities from feeling socially isolated. Among the facilitates available to people was a cinema, activity room, hairdressing salon and a private dining room.
The registered manager led a senior leadership team which had clearly defined roles and responsibilities. There was an open culture within the service and feedback from people, relatives and staff was regularly sought. The quality of care and support people received was subject to in-depth checks and audits. The provider utilised the services of external agencies to achieve positive outcomes for people and engaged in partnership working within the local community.