Lavender Fields

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good.

At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to consent and treatment.

This service scored 29 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Initial assessments before admission and re-admission from hospital were poorly completed by staff who had not been trained or upskilled to complete the task.

Assessments of people’s needs did not contain critical information, to enable the development of individual, detailed care plans and risk assessments. Individual needs and areas of high risk were not appropriately scored to ensure critical information was pulled through to the front page on the electronic care planning system to alert staff of high risks to be aware of. Care staff and agency staff did not have quick access to the most important safety information about a person’s care, in situations where they had not had time to read people’s full care plans before providing individual care and support.

There was no evidence people or their relatives or friends had been involved in reviews of their care. People and relatives told us they had not been involved, and some were unaware there was a care plan.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

People’s care and support plans and their risk assessments had not been comprehensively reviewed to ensure information was accurate or contained important information and guidance.

Although staff had used nationally recognised tools to assess risks to people such as malnutrition and skin integrity. These were not always recorded regularly and not referred to in people’s care plans or risk assessments, to enable preventative measures to be put in place. A person’s skin integrity assessment showed they were at very high risk of damage to their skin. Staff had not completed any further assessments to ensure preventative measures were in place since April 2025.

Where people’s health was poor which meant staff were unable to weigh them to monitor and assess of their risk of malnutrition, other forms of best practice to measure weight loss were not used. The lack of consistency and staff skills to ensure close monitoring of people’s health meant timely measures may not be put in place to support their health and well-being.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

Staff did not engage with external healthcare professionals to ensure the care and support people were receiving was appropriate to their needs. Staff did not make referrals to therapists to improve people’s mobility and told us they needed to go through a GP, and referrals can “take ages”. There was no evidence referrals took a long time to be considered by health care professionals as referrals had not been made.

The service did not establish effective communication and information sharing within the team. For example, there was no evidence team meetings took place regularly, or that staff handovers between shifts were used effectively.

Relatives told us, “There’s not enough staff. (loved one) is hoisted which means 2 staff off the floor, several people need hoisting, someone may be in distress at that time.”

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

Staff had not received training to support important healthcare needs such as catheter care, epilepsy or Parkinsons disease, even though people were living at Lavender Fields with these care and support needs. We found that care plans and risk assessments, completed by staff, did not address the important factors and risks in relation to these needs. People and their loved ones could not be assured their needs were being safely or fully met.

Agency staff had not received an appropriate induction into the service, and the provider had not ensured they had received confirmation that agency staff had been trained in catheter or stoma care. This meant the provider had no assurance permanent or agency staff on duty had been suitably trained to support people with their health needs.

One person’s catheter required changing every 12 weeks. Reviews by staff until June 2025 stated that the catheter needed changing in February 2025. No record was made to confirm this had happened and staff did not know when it was last changed. Although district nurses were responsible for changing the catheter, staff had not ensured their own monitoring records to advocate for the person if there was an error in the district nurse system. The provider had not recognised or addressed these shortfalls.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

People’s care plans had not been monitored to check they included accurate information and there was no process to monitor outcomes for people.

We found no evidence of records to monitor people’s needs such as epileptic seizures, catheter changes, stoma changes, mobility and falls to establish possible trends or patterns. There were risks peoples’ needs were not met leading to complications with their health, and risks were not identified and mitigated against, leading to poor outcomes.

A relative shared, “The lack of monitoring is inadequate, they should be checking at night”.

Care plans did not always include if people had goals, such as to increase their mobility to gain or maintain independence. Monitoring processes were not in place to identify this, leading to a risk to people’s health and well-being.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The service did not consistently act in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice, or their own MCA policy. The provider and staff’s lack of knowledge and understanding of MCA and what it means in practice meant people’s rights may not always be maintained and upheld.

Mental capacity assessments were not always completed for the relevant decisions that needed consent and a robust best interest decision making process had not always been followed. Consent forms were often not signed and sometimes had been signed and agreed by a relative without evidence of the appropriate legal authority. When people had been assessed as having capacity, they had not always signed consent forms in relation to their care and treatment or agreement to their care plan.

The provider had installed restrictive equipment such as sensor mats or passive infrared sensors in people’s rooms, to inform staff if people were moving or attempting to mobilise independently. There was no evidence why these were required, and the provider had failed to ensure capacity assessments were always in place to assess peoples’ ability to understand and consent to the devices intended to restrict their freedom of movement.