Lavender House Residential 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 requires improvement. At this assessment the rating has remained 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. Systems and records were not always robust enough to demonstrate risks to people’s health were effectively monitored.

The provider was in breach of the legal regulations relating to good governance.

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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider did not have the processes in place to demonstrate they listened to and acted upon concerns. The provider could not demonstrate they were open and responsive to suggestions to help drive improvement. There had not been any staff or resident surveys to collate this information.

However, the provider celebrated different countries and religions from around the world by having themed days to help staff support a more diverse culture for people and staff to understand people’s different cultures. The registered manager stated, “We want to be a home from home.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Whilst leaders had the skills, knowledge and experience to lead with integrity, openness and honesty, governance processes were not managed effectively.

Staff we spoke with told us the managers were knowledgeable and supportive. One staff member said, “I feel supported by the managers, they will listen and will sort it out.” Another staff member told us, “The managers are very good at their jobs.”

The provider did not have systems in place to encourage staff to feedback, for example, through staff surveys. Most staff said they would be happy to approach the registered manager directly; however, one person did not feel their feedback would be treated confidentially and another staff member told us, “We don’t really receive encouragement to speak up.” This was fed back to the registered manager who was surprised to hear this and stated, “My door is always open, staff have access to me all the time, I am on site, I am a very hands on manager.” The director’s phone number was in the staff room, should staff wish to make direct contact.

The provider had policies and procedures in place which guided staff through several ways they could speak up about any concerns they had about people’s care. This included how they could contact the owner directly and how they could raise concerns externally to other agencies if they felt they were not being listened to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had recruitment, flexible working and equality and diversity policies and procedures in place which were effective. An example of how a staff member had been supported with a reasonable adjustment was provided by the registered manager. Three staff members confirmed their working availability had been accommodated in line with their personal circumstances. One staff member said, “I could not do the same hours and they [the provider] accommodated me.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Issues identified by the provider in relation to medicines, training and infection prevention control audits were not rectified in a timely manner and action plans were not effective. For example, signatures were missing on medication administration records in April and October 2024 and this was still an ongoing issue in January and February 2025. Staff did not follow policy in line with reporting medication errors which stated to contact the GP, record the error and contact family members. Error forms were available to staff for completion; however, they were not being completed meaning the provider did not have clear oversight to mitigate future risks.

The registered managed stated audit frequency had increased from 6 monthly, to quarterly and due to continuing issues, the frequency had further increased to monthly to help address these matters.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. For example, after receiving feedback regarding unclear guidance around covert medication, the provider liaised with the appropriate health professionals to collaboratively find a solution. A health professional told us, “People are very well looked after.” One person told us they enjoyed activities out in the community and another person enjoyed the fortnightly visit from church.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was a lack of robust systems in place to capture feedback to enable the provider to learn and make continuous improvements. Two staff told us they were not encouraged to share their views to make improvements, and improvements identified in audits were not always cascaded to the team effectively. We discussed this with the registered manager who confirmed learning and improvements were not always documented, however, this would be implemented going forward.