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Lavender Court Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 January 2019

Lavender Court is a ‘care home’ without nursing. People in care homes receive accommodation and nursing or 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.

Lavender Court provides adapted accommodation and care for up to seven people with learning disabilities. At the time of our inspection there were seven people using the service, supported in the home by 17 permanent staff. Some of these staff were allocated to the home from another service which was closed for refurbishment. At the time of the inspection there were plans to rota the staff across the two services when it re-opened in the new year.

The property is a large bungalow with seven bedrooms, communal spaces, a rear garden and is close to local amenities. The home was closed between January to July 2018 for a refurbishment project which adapted the premises for people with mobility needs and to provide en-suite facilities.

This inspection took place on the 17, 18 and 22 October 2018. We returned on the 30 October 2018 to provide feedback to the registered manager and operations manager who were both on annual leave during our inspection on the 22 October 2018. The inspection was unannounced on the first day of inspection which means we did not provide the service with warning of our visit. Subsequent days were announced.

The provider is required to have a registered manager as part of their conditions of registration. 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. At the time of our inspection, there was a manager registered with us.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

At our last inspection we found breaches of Regulation 12 (Schedule 3), 15 and 18 of the Registration Regulations 2009 and Regulations 9, 12, 16, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service received an overall rating of requires improvement.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) safe, effective, responsive and well led to at least good. At this inspection we found there were repeated breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider did not have satisfactory arrangements to manage individual’s risks and safety. Records were not suitably maintained, accurate and up to date and the governance of the service failed to bring about the improvements required for them to become compliant.

Systems did not always ensure that vulnerable adults were protected from foreseeable risks. People’s risk assessments were completed but were not always clear or accurate and did not contain sufficient information to identify or mitigate risks. The service did not use an effective method to calculate staffing deployment.

The governance of the service was unsatisfactory. A quality assurance tool had recently been developed but was not comprehensive, and not always acted on promptly or sufficiently. Records were not always up to date or appropriately filed. There was not sufficient day-to-day management oversight of the home or enough time allocated to senior staff to achieve delegated management duties.

The service had made improvements to staffing levels whic

Inspection areas


Requires improvement

Updated 15 January 2019

The service was not always safe.

People's risks were not clearly identified or mitigated.

Premises risk and safety records were not always up to date.

Staffing levels had increased which was an improvement.

People were protected from abuse or neglect.

People's medicines were managed safely.



Updated 15 January 2019

The service was effective.

The service had made improvements to staff training, supervisions and appraisals.

The service was compliant with the Mental Capacity Act (MCA) 2005.

People were supported to access healthcare services.



Updated 15 January 2019

The service was caring.

People were treated with kindness.

Care plans included people's individual wishes and preferences.

People's privacy and dignity was respected.



Updated 15 January 2019

The service was responsive.

People's care plans were person-centred and comprehensive.

Staff had good knowledge and understanding of people's needs.

People's access to opportunities in line with their interests in the home and the community had improved.

Information about and in response to complaints was clearly documented which was an improvement.


Requires improvement

Updated 15 January 2019

The service was not always well-led.

Records about people's care and service safety checks were not always up to date or filed appropriately.

Audits were not used effectively to monitor the quality and safety of the service.

There was not sufficient day-to-day management oversight of the home.

There was not a robust system to investigate or share outcomes of incidents and accidents to ensure learning took place.