Lavender Lodge Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

At our last inspection the provider was in breach of the legal regulation in relation to safe care and treatment. At this inspection improvements had been made and the provider was no longer in breach of this regulation.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Since our last inspection, the provider had developed a proactive and positive culture of safety. They had now implemented a robust system to report, review and analyse accidents, incidents and falls. A monthly analysis of accidents, incidents and falls was completed which looked at themes and trends to support in mitigating risks to people. For example, the time of day or location of an incident, and whether the incident occurred when staff were supervising.

Relatives told us they were well informed when their loved one was involved in an accident, incident or fall. Relatives confirmed they were satisfied with how they were managed. No concerns were raised about safety. One person told us, “I get support when I need it, I feel so safe here.”

Lessons were learned to identify and embed good practice. These were shared with staff during daily flash meetings. Staff feedback confirmed they spoke about learning, and outcomes from accidents, incidents, falls and safeguarding.

The provider worked with partner agencies to ensure safe systems of care. A visiting professional told us staff knew people’s needs well. People, relatives and relevant professionals were involved in reviewing people’s care and support.

Information about people’s needs was shared and understood by staff. Staff met daily to discuss people’s health and support needs, professional involvement and advice. The providers policies had information on how and when to make referrals to relevant agencies. For example, a dysphagia policy provided guidance on making a referral for a swallowing assessment if a person was showing signs of swallowing issues.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider now initiated internal investigations and immediate actions to improve safety where concerns about abuse were reported. This ensured people were protected from the risk of abuse or harm. Safeguarding was routinely discussed with the staff team, which helped to promote awareness of safeguarding.

People and relatives, we spoke with confirmed they felt safe using the service. Our observations showed people were comfortable and relaxed around staff. One person told us, “I feel very safe here."

Training records showed staff had completed mandatory safeguarding training.

Deprivation of liberty safeguards (DoLS) were appropriately applied for and monitored. DoLS are required to protect individuals who lack mental capacity and are potentially being deprived of their liberty in a care setting.

At our last inspection, we found risks to people were not always identified or assessed. During this inspection we found improvements had been made and risks were now identified and assessed. We identified some minor inconsistencies within some people’s risk assessments, for example where people needed re-positioning regularly to support their skin integrity, it was not always clear how frequently someone needed this support. However, we found daily records showed people were receiving safe care to support their needs. The provider explained they were aware of further improvements required regarding care plans and risk assessments and work was in progress to review and address this.

Clear guidance was now in place to support people who were prescribed medicine to people who communicated signs of distress. The electronic system prompted staff to be alert for specific signs and symptoms of distress, and consider less restrictive interventions to support people before administering medicine.

Improvements had been made in ensuring people and their relatives were involved in their care planning, or assessment of risks.Relatives confirmed they had been involved in recent reviews of people’s care.

We observed safe moving and handling manoeuvres being carried out by staff, and staff responding to people communicating signs of distress in line with their care plans. One staff told us, “We get chance to read people’s care plans and risk assessments to understand them. We are told to ask questions.”

The provider had rolled out specific training to ensure staff were confident in supporting clinical risks to people.

Some areas within the environment remained in need of attention. For example, some bedrooms needed painting and some and fixtures were worn. Relatives felt some areas within the service were tired and in need of re-decorating. There continued to be a lack of signage to support people to navigate through the building.

However, the provider was continuing to work through a refurbishment plan and since our last inspection we found some areas had been redecorated. We were assured all areas would be addressed. People and relatives commented on improvements in the overall cleanliness of the environment and equipment since our last inspection. One person told us, “The home is cleaner than it was, and they are doing more painting and decorating.” People had access to well-maintained equipment and facilities. The provider was able to demonstrate oversight of health and safety checks on the environment.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.