Lavender Fields

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, safeguarding people from abuse and improper treatment and safe staffing.

This service scored 31 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Accidents and incidents had not been monitored and analysed to identify themes, mitigate risks and prevent further occurrences. An overall view of accidents and incidents to learn lessons and keep people safe by ensuring the appropriate mitigation measures were in place, had not been undertaken since December 2024. The provider had failed to ensure appropriate action had been taken to reduce the risk of falls, especially when people had fallen from their bed and injuries had been sustained.

There were incidents where people had fallen, witnessed and unwitnessed, which resulted in injuries. For example, a person had fallen, causing injury and hospitalisation. On discharge from hospital, they continued to have unwitnessed falls, in various rooms while walking around. Although these incidents were recorded, the persons care plan and risk assessments had not been updated to ensure mitigation was in place to prevent further falls and potential serious injury. Another person fell from their bed and the incident record stated their care plans and risk assessments would be updated. The records were not updated, and the person fell from bed again 2 days later.

Although investigations had taken place into individual incidents, the provider had not identified patterns and trends or acted to reduce risk of re-occurrence. The provider had failed to ensure people’s safety by failing to closely monitor and learn lessons.

A culture of learning lessons was absent, the approach to ensure staff were learning from accidents and incidents was inadequate leading to unsafe care within the service.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

People’s safety was not robustly monitored or managed. Risk assessments were not always adequate, and some risks had not been assessed appropriately, reviewed or mitigated. There was a risk the information passed to other agencies such as hospital staff would not be accurate information about people’s care needs and support. Permanent staff knew people well but there was a risk people could come to harm when being supported in hospital by staff who did not know them well and their needs and risks were not adequately recorded.

Assessments carried out when people were in hospital and due to return to the service were not completed appropriately or fully. Staff undertook an assessment with one person who was ready to be discharged from hospital and wished to return to the service. The assessment contained very limited information about their current needs. However, the person’s relatives told us they had been told by staff the provider had refused the person’s return based on the assessment.

People had not been referred to healthcare professionals such as occupational therapy or physiotherapy to ensure a safe approach was taken to assessing people’s mobility needs and advising on the appropriate equipment staff should use that met their needs and was safe. The provider had not ensured a joined up approach to safety by a failure to access healthcare professional assessment and advice in relation to people’s mobility needs when they needed it.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Not all events, such as accidents and incidents that may constitute the abuse of a vulnerable adult were raised with the local authority, in line with safeguarding vulnerable adults’ protocols. For example, a person had raised a concern around their safety with staff. Staff had reported this to a member of the management team. However, the person’s concerns in relation to their safety had not been referred to the local authority safeguarding team, whose responsibility it is to investigate allegations of abuse. The management team had not been transparent about the incident, which placed the person at risk of further abuse.

Another incident had been raised by a staff member in relation to how a person was treated and spoken to by another member of staff. The incident was recorded and investigated, however, the staff member carrying out the investigation had not referred to the local authority as per safeguarding adults’ protocols. The lack of transparency and not following safeguarding protocols meant people were placed at risk.

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

The provider failed to do all that was reasonably practicable to keep people safe from avoidable harm.

Staff did not have the guidance necessary to provide safe care for people living at the service.

People’s individual risk assessments were not updated following incidents, such as significant falls where people had sustained an injury. One person had fallen and sustained a fracture needing hospital treatment. When they returned their mobility needs had changed. Their care plans and risk assessments had not been updated to ensure care staff and agency staff had up to date information to ensure the provision of safe care.

People’s care plans were general and not specific to individual needs, which would often vary. People who had health conditions such as epilepsy did not have care plans and risk assessments that reflected their specific needs, such as how people’s seizures presented or what the triggers were. One person’s epilepsy care plan and risk assessment recorded guidance for staff that was not in line with best practice and guidance given on the NHS website when supporting people having a seizure. Other risks such as when bathing, or what to do if the person had a seizure when sitting in their wheelchair had not been included. This placed people at risk of receiving care that did not meet their needs.

Risks associated with a person’s Parkinson’s disease were not individual. Although a risk of increased tremors had been identified if the person did not receive their medicines on time, the risk assessment did not identify why this was a risk, such as the increased risk of falls and reduced quality of life. A falls risk assessment recorded the person had falls in the last 12 months but did not factor in the risks associated with Parkinson’s disease.

Where there were changes in people’s needs, for example, from being independently mobile to requiring the use of equipment such as a full hoist, their individual risks had not been re-assessed to make sure staff had the appropriate guidance to ensure people’s safety. Staff had assessed people's mobility needs, without completing referrals to the appropriate healthcare professionals, or seeking interim advice while waiting for the referral to be processed. This meant staff made decisions about the equipment people needed to transfer from bed to chair and vice versa in isolation, including without the guidance of a manager when there wasn’t one in post.

The guidance in place for staff and agency staff was inadequate and did not describe the care and support people needed to stay safe on a day-to-day basis.

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

Although the environment was clean and spacious, and servicing of equipment was completed regularly, the provider, had failed to ensure equipment used by staff to support people to move around, such as hoists and slings were the correct size and type for individuals. This could lead to unsafe care delivery.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staff had not had the opportunity to have regular 1:1 supervision meeting with a line manager or access to regular support. There was a risk without effective supervision staff’s performance, skills and ability may not meet the required standards to ensure people’s safety and identify support mechanisms for staff if improvements were needed.

Staff had not been trained to carry out their roles in specific areas, such as moving and handling assessment, assessment of care and support needs, catheter care and Parkinson’s disease.

Senior care staff had made decisions on how to meet people’s mobility needs without training or expertise. They did not make any referrals for advice and guidance to trained healthcare professionals to ensure the decisions made were safe. The provider did not ensure that staff had the necessary and up to date training required to keep people safe.

Senior care staff were completing assessments of people’s needs before moving into the service, or when they had a stay in hospital and were ready to be discharged. The staff undertaking assessments had not been trained to do so nor had received coaching and mentoring to develop the skills.

Staff were making decisions about people’s health and care such as whether they were well or when people needed medical assistance, when they had not received basic first aid training. The provider had not ensured staff were suitably trained to make these decisions in the absence of a manager which placed people at risk of receiving unsafe care.

The service was short of permanent staff, there were a significant number of staff vacancies, leading to a high use of agency staff across all shifts. This included a shortage of senior care staff, so agency staff were also covering these shifts. There was a greater risk of a lack of consistency in staff practice, increased further by the lack of appropriate guidance in people’s care records about their specific care needs.

A relative told us, “Generally, they are very good and care a lot but it’s not good for the residents with all the changes in staff, difficult for the staff to get to know people.”

Staff had been recruited safely; the required checks had been completed to make sure staff were of good character.

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.

People requiring the use of a hoist to move around did not have access to their own slings, communal slings were not laundered regularly between uses, leading to a risk of infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in care planning.

Staff who were responsible for administering people's medicines were required by the provider to complete medicines training annually and to have their competency assessed 3 times in a 12-month period. This had not happened. Errors had occurred and there were no assurances all staff who administered people’s medicines were competent to do so.

People’s medicines care plans identified needs such as people with Parkinson’s but not that medicines people required were time specific and what the risks were if they were not administered on time, to ensure staff understood the effects on people. A person’s care records contained unclear instructions such as, ‘I have Parkinson’s Disease which I might be difficulty for me most time to use my tablets, I will like staff to provide the relevant tools in using my tablets’. The records provided no clarity for staff administering medicines. We found evidence of people’s Parkinson’s medicines not being given at the specifically prescribed times which exposed them to the risk of serious harm.