Lavender House Residential 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 good. 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 people could be harmed. Improvements were required relating to the safe administration and management of medicines. Staff refresher training had lapsed, and staff did not receive regular supervisions.

However, staff were recruited safely and received an induction when they first started working at the service. We observed staff supporting and caring for people in a safe and compassionate way.

The provider was in breach of the legal regulations relating to people’s safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Staff did not always listen to concerns about safety and staff did not always report safety events. Lessons were not always learnt to continually identify and embed good practice. There was a lack of effective systems in place for people and relatives to feedback. For example, the provider did not carry out surveys for staff, people and relatives to raise concerns.

However, staff knew how to report safety events and told us, “I would not hesitate to report anything” and “I would escalate to the manager.” Relatives told us they could raise a concern, and they were informed if anything happened to their family member. One relative said, “They let me know if anything happens.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager was able to explain the pre-admission process and records evidenced an assessment of people’s needs was completed prior to commencement of the service. Staff told us they got to know people’s needs through handover meetings and via the provider’s electronic care planning systems. This electronic system enabled the provider to provide up to date information to healthcare partners when required.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff did not deal with one incident effectively and the registered manager was unaware of the extent of this incident until they were contacted by CQC. The provider did not always share concerns quickly and appropriately with external professionals.

However, people told us they felt safe. Staff were able to demonstrate their knowledge of safeguarding and the actions they would take to ensure people were kept safe. Staff told us they received training in safeguarding and would report any concerns where necessary, however, we identified only 13 out of 21 staff did not have up to date safeguarding training.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found care plans did not always have sufficient information to keep people safe. For example, where people required support with episodes of emotional distress, they lacked sufficient detail to guide staff in how to support people appropriately, effectively and safely. We observed unsafe use of equipment. For example, brakes were not applied to a wheelchair which could have caused harm. Staff rectified this immediately when we pointed this out. Accidents and incidents were not analysed regularly to help identify trends and themes and preventative measures were not implemented in a timely way.

However, people were supported to take risks that enhanced their quality of life and independence. This included going out to the local village independently and making their own drinks.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Water temperature checks within two people’s bedrooms recorded temperatures above the recommended guidance with no actions taken to lower the temperature, putting people at potential risk of scalding. We identified some fire doors were either blocked, propped open or required adjustment. One person did not have a personal emergency and evacuation plan (PEEP) in place. The purpose of the PEEP is to ensure staff know how to assist people to evacuate the building safely in the event of an emergency. This meant staff did not have the key information they needed to assist this person safely from the building putting the person and staff at risk. We discussed these shortfalls with the provider, who took immediate action to address these issues.

The provider had a fire risk assessment in place to help ensure people could be removed from the building safely in an emergency and regular fire drills were carried out. However, not all staff had been included in these drills. The registered manager was working towards ensuring all staff had the opportunity to take part in fire drills.

The service had enough staff. However, they did not always make sure staff received effective support, supervision and development. Staff received an induction when they first started working for the service, however, refresher training, in varying topics, had not been completed by 17 out of 22 staff. Over half of the staff did not have up to date safeguarding, infection control nor health and safety training. This was discussed with the registered manager who immediately booked training courses and supervisions for staff to attend.

Staff worked together well to provide safe care that met people’s individual needs. The provider followed safe recruitment practices and had ensured appropriate pre-employment checks were completed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified several items of equipment and furniture that required replacing due to their protective layer being cracked and damaged. This increased the risk of cross infection. This was discussed with the registered manager who immediately replaced the items.

However, we observed staff did use personal protective equipment (PPE) appropriately and posters on handwashing were on display. Six staff told us the service was clean, with plenty of PPE, however 2 staff told us the provider ran out of gloves recently and these were ordered immediately. One relative told us, “It could be dusted more in the bedrooms.”

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider could not demonstrate people had received their medicines safely, as prescribed and in line with best practice guidance. We identified concerns relating to the safe administration and management of medicines. For example, records reviewed identified 2 people had a missed doses of their medication with one person’s medication being out of stock for 8 days. No actions were taken to obtain the medications without delay and no medical advice had been sought. This posed a risk of the medication being less effective and peoples’ symptoms and medical conditions worsening. We found a tablet on the floor in a person’s bedroom, it was unclear when this had been administered. This posed a risk to the safety and wellbeing of others and a risk to the person who had not taken their prescribed medication.

Staff did not have clear guidance how to safely administer covert medicines and other health professionals had not been consulted when people received their medication outside the prescribed administration time. This posed a risk to the safety and wellbeing of people.

When we fed this back, the provider was responsive and took immediate action to resolve the issues. We observed staff administering medications with a person-centred approach and asked for consent from people before administering medication.