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We are carrying out a review of quality at Lavender Court Care Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection summaries and ratings from previous provider

Overall summary & rating


Updated 24 May 2018

Sunningdale House is a care home which offers care and support for up to 36 predominately older people. Some of these people were living with dementia.

The service was last inspected in July 2017 and was rated as Good. In February 2018 we received serious concerns from health and social care professionals about the care that people received. The concerns were in relation to end of life planning, personal care needs not being met, medication, medical concerns not being escalated to health professionals in a timely manner, staffing levels, staff culture, infection control practices, lack of confidence in record keeping, and a higher than expected number of deaths. Due to these concerns we brought our inspection forward.

This comprehensive inspection took place on 26 March and 3 April 2018 and was unannounced. Two inspectors and a Specialist Advisor visited the service on the 26 March 2018. At that time 19 people were living at the service. Two inspectors visited the service on the 3 April 2018, at that time 6 people were living at Sunningdale house.

Due to the high level of concerns commissioners reviewed all people they funded. Prior to the inspection 11 people were moved to nursing home provision so that their health and social care needs could be met. From the 26 March 2018 a further 16 people were moved to other care provision.

The service is required to have a registered manager. The registered manager handed in their notice in January 2018. On being informed of the concerns, the provider promptly deployed their operational management team to address the concerns and support the service. On the 3 April 2018 an interim manager was appointed at the service.

Care staff had not received training in safeguarding and had limited or no knowledge about the safeguarding process and how to recognise potential signs of abuse or mistreatment. They were unable to tell us who they would report concerns to outside of the service. A staff member commented “People have been unsafe but we didn’t know. Even the things we thought we were doing right we weren’t.”

Care records were kept electronically and stored securely on computers and laptops. Staff recorded on hand held electronic devices when they had supported people with personal care. The devices were also used to update any monitoring records such as food and fluid charts and repositioning records. All staff were required to record on the devices when they had completed a task which sometimes meant tasks were recorded twice if two staff had been involved in the delivery of care.

Some people’s care plans, were not effectively updated to ensure they were reflective of people's current care needs. Following commissioner’s reviews of people’s care needs, it was evident that some people’s health needs had changed. This meant that people’s health needs had not been reviewed appropriately by the service to ensure they could continue to meet the person’s current health and care needs.

People’s risks were not safely managed at the service. For example, a number of people were at risk of falling out of bed. There was no relevant risk assessment in place or documentary evidence to support how the risks could be minimised to keep the person safe. Consultation with those involved with the person was not evident. Therefore we were not assured that risks had been properly considered and addressed.

The operations manager had developed a new handover system as they were aware that, due to the lack of accurate care plans, staff had limited guidance, information or direction in how to meet people’s needs. The operations manager was aware that this needed to be developed further.

Arrangements for the management of medicines were ineffective. There were some gaps in Medicine Administration Records (MAR) charts. The management of Controlled Drugs (CD) were not robust. This meant that it was not always possible to identify if people had received their medicines as prescribed.

There was no e

Inspection areas



Updated 24 May 2018

The service was not safe.

People were not always protected against the risk of abuse or mistreatment because not all staff had received recent training in this area.

Risks to people were not being adequately assessed or addressed to keep people safe.

Medicines were not always administered correctly, managed or stored securely. This meant there was a potential risk of errors and people might not receive their medicines safely

People who used the service were put at risk because cleanliness and hygiene standards were not maintained. We observed poor infection control practices which put people at risk.



Updated 24 May 2018

Staff did not have an understanding of the legal requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards. For some people restrictive practices were in place without evidence of consent or adequate assessment and authorisation.

Staff did not receive appropriate induction and training so they had the up to date skills and knowledge to provide effective care.

People’s healthcare needs were not always met, for example around pressure area care. We received mixed feedback from health professionals, with both of those we spoke with raising concerns over some aspects of care.


Requires improvement

Updated 24 May 2018

The service was not always caring.

People’s privacy and dignity was not always protected.

Staff did not always know the needs of the people they supported.

Staff spoke about people fondly



Updated 24 May 2018

The service was not responsive.

The service failed to respond to people's changing needs by ensuring amended plans of care were put in place. This meant people did not always receive support in the way they needed it.

People had no access to activities within the service.

There was a system in place for receiving and investigating complaints. However people and relatives stated they were uncertain how to access it.



Updated 24 May 2018

The service was not well led.

There was a lack of communication and involvement from the manager to staff.

Staff felt disempowered and unable to raise suggestions.

We found a number of concerns during our inspection which had not been identified by the provider or manager. This showed a lack of robust quality assurance systems.

Records relating to the management and running of the service and people's care were not consistently or adequately maintained.