Lavender Lodge Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At our last inspection the provider was in breach of the legal regulation in relation to good governance. At this inspection improvements had been made, and the provider was no longer in breach of this regulation.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Significant improvements had been made on the overall culture at the service. The provider had committed to investing in the leadership, staff, quality and compliance which had impacted positively on the culture. The provider’s visions and values were shared by staff and leaders and communicated with people who used the service.

This was reflected in feedback received. One person told us, “It seems more vibrant here now.” Another said, “There are more activities and staff are interacting better – on the whole it is getting better.” A visiting professional said, “The service is tidier and more organised.” Staff feedback included, “I like the person-centred care and meaningful connection with residents.” And, “Things are so much better, it feels like a nice workplace.”

During our inspection we observed a warm and lively atmosphere within the service. People and staff were engaged with each other and interactions were respectful.

Since our last inspection, the provider had instructed an external management consultancy service to provide intense management support to the service. They were working in partnership to ensure leaders were competent and supported in driving improvements. This included a 12-week induction, with clear objectives and regular supervision.

During our inspection we identified some significant events which CQC had not been notified of as per the providers regulatory responsibility. These were submitted retrospectively.

We received positive feedback from people, relatives and staff on the visibility and approachability of management. One staff told us, “[Manager] is so supportive, we have 24/7 support now from the consultants.”

Overall, the provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff all confirmed they felt able to raise concerns. Most staff felt they would be listened to, but some fed back they hoped further improvements would be made in ensuring all staff in all roles were equally listened to.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Since our last inspection, an external management consultancy service had been supporting the overhaul of governance systems at the service. A range of audits, checks and reports were now in place which were regularly completed and allowed for oversight.

Further work was required to ensure governance systems were sustained and embedded to ensure ongoing compliance, as we were not yet able to see the full impact. For example, the provider’s governance systems had identified improvements required to ensure consistent and sufficient details within care plans, but at the time of our inspection this had not been completed.

Plans were in place to safely transition to a digital auditing system to further improve oversight of key risk areas within the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There was a strong focus and commitment to driving improvement at the service.

The provider had instructed support from an external management consultancy service with the view to make the necessary improvements and address the areas of concern found at our last inspection. They had developed a clear and comprehensive action plan which was regularly reviewed and updated with actions from both internal and external systems.

Staff felt involved in the changes and felt positive about the direction of travel for the service. They confirmed they had been made aware of our last inspection findings and were asked to attend a meeting and confirm they understood where the areas of failure were. This ensured staff were informed of where improvements were required, and how these were going to be achieved.