We carried out a review of the data available to us about Lilac Lodge & Lavender Cottage 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 Lilac Lodge & Lavender Cottage, you can give feedback on this service.
At the last inspection on 2 February 2016, we asked the provider to take action to make improvements (for example to staffing levels), and this action has been completed.
People and their relatives told us they felt safe living in the service. Improvements had been made so that risks to people were appropriately planned for and managed. Medicines were managed, stored and administered safely.
People told us there were enough competent staff to provide them with support when they needed it. We observed that improvements had been made to the numbers of staff available to support people.
Staff had received appropriate training, support and development to carry out their role effectively. Staff were given opportunities to feedback their views on the service and make suggestions.
People received appropriate support to maintain healthy nutrition and hydration.
The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLs). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People told us staff treated them with kindness and upheld their right to dignity and respect. This was confirmed by our observations. People and their relatives were given the opportunity to feed back on the service and their views were acted on.
Staff knew people individually and were aware of their preferences. Further personalisation of new care records being implemented is required.
People were given appropriate support and encouragement to access meaningful activities and follow their individual interests. Improvements to the provision of activities were being made.
People and their relatives told us they knew how to complain and were confident they would be listened to if they wished to make a complaint.
The manager and senior management team worked hard to create an open, transparent and inclusive atmosphere within the service. People, relatives and staff were invited to take part in discussions around shaping the future of the service.
There was a robust quality assurance system in place and shortfalls identified were promptly acted on to improve the service.
Further information is in the detailed findings below.
The inspection was unannounced and took place on 2 February 2016.
The service had in place a manager who had applied to be registered. 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.
The leadership of the service had been working on an extensive improvement plan to improve the service. This was a work in progress but people, relatives, visitors and staff were positive about the changes being made and were contributing through sharing ideas and discussion.
People and their relatives told us they felt the service was safe. Improvements were required to ensure that clear plans were in place that reflected how staff could reduce the risk of people coming to harm. Staff, the registered manager and senior leadership team understood their role in keeping people safe.
People told us and our observations confirmed that there were not consistently enough staff to meet people’s physical and social needs.
We observed that staff were competent in providing safe and effective care to people. Staff told us they received the training they needed to carry out their role effectively, and that they were supported to do their job. Improvements were required to implement a system to monitor the competency and practice of staff.
There was a robust recruitment procedure in place to ensure that prospective staff members had the skills, qualifications and background to support people.
Medicines were stored and administered safely. There was a system in place capable of identifying errors.
The service had made the appropriate Deprivation of Liberty Safeguards (DoLS) referrals for people using the service and was complying with the principles of the Mental Capacity Act 2005 (MCA).
People were supported to remain independent. We have made a recommendation around how peoples care records can be personalised and around ensuring that people are consistently supported by staff to engage in meaningful activity.
We observed, and people told us, that the staff were caring, kind and treated them with respect.
Improvements were required to ensure people and their representatives (where appropriate) were involved in the planning of their care. Improvements were also required to ensure that people’s views were reflected in their care records and that these records were personalised to them as an individual.
We observed that people were supported to eat and drink sufficient amounts. Improvements were required to ensure that care records were clear about what preventative action had been taken when a risk of malnutrition or dehydration was identified.
There was a robust quality assurance system in place which we saw was capable of identifying shortfalls in the service so these could be addressed.
There was a complaints procedure in place and people knew how to complain if they were unhappy. People and their representatives were supported to feed back their views on the service and these were acted on by the manager.
We looked at the service's safeguarding procedures and spoke to staff about safeguarding vulnerable adults from abuse. The staff we spoke with were aware of the different forms that abuse can take and how to report concerns. The training records showed that staff had all received training in safeguarding and in a range of other areas.
The premises were clean and decorated well and people who used the service had a number of areas throughout the service were they could sit and relax. A variety of activities and entertainment were arranged, and details of forthcoming events were on a notice board in the hall.
A quality assurance process was in place to ensure that the views of people using or involved with the service were gathered and used to promote change where required.
During our visit on the 28 November 2012, we found that some progress towards improving individual people's records had been made. We were told by the newly appointed manager and staff that further action was planned to ensure that clear documented risk assessment and care plans were established.
We also saw that some progress had been made to improve the environment and cleaning practices. Further work is in progress to enhance security practices.
People who used the service told us that they felt safe and well looked after by the staff. One visitor told us that their family member 'Enjoyed living here,' and that they felt safe.
Three people told us 'We love it here but it is very hot." One person told us that was why they liked to sit by the window as it was so much cooler.