About the service Lavender Oaks Care Home is a residential care home providing personal and nursing care to 56 people at the time of the inspection. The service can support up to 75 people within four suites in one purpose-built building.
People’s experience of using this service and what we found
People did not always receive care and treatment that was safe, because there was not always sufficient information available to staff about how to manage people’s risk of developing pressure ulcers. For people who already had pressure ulcers, there was not enough information for staff to ensure the correct care and treatment to promote healing and prevent further damage. We also found there was not enough information about people’s medicines for staff to ensure people received “as required” medicines when needed, although other medicines were managed safely.
Other risks to people’s safety were assessed and managed safely, although in some cases detail was missing from people’s mobility assessments. Staff checked the premises and people's individual mobility equipment to ensure they were safe for people to use.
Although the provider had systems in place to monitor and improve the quality of the service, these required some improvement as they had not identified the issues we found around risk assessment and management.
The provider had systems to assess the staffing needs of the service, based on the level of support people required in different parts of the home. Although there were enough staff to care for people safely, there was still a need to further review how staff were deployed because a large proportion of falls happened when people were alone in their bedrooms.
There were effective systems in place to protect people from the risk of abuse and to control infection. Staff were recruited safely. When accidents and incidents happened, the provider had systems in place to learn from these and prevent things from going wrong again. They had completed a thorough analysis of falls to identify trends and took effective action in response to lower this risk.
People’s needs were assessed, and reassessed when needed, in line with guidance and best practice. Staff worked well with other agencies to do this. Staff received the training and support they needed to do their jobs well, although we did not find enough evidence to show nurses received regular supervision. We will check this again at our next inspection.
People received support to eat and drink enough to stay healthy, and to attend healthcare appointments when needed. The environment was suitably adapted to meet people’s needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People, relatives and staff had opportunities to feed back their opinions of the service. The registered manager understood their regulatory requirements and was open and honest with people when things went wrong. They listened to people’s views and acted on them as part of continually improving the service, and worked well in partnership with others.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 6 August 2019).
Why we inspected
The inspection was prompted in part due to concerns received about an increased number of falls leading to serious injuries; staffing levels; medicines management; management of people’s health conditions and continuing care when people returned to the home from hospital. A decision was made for us to inspect and examine those risks.
We undertook a focused inspection to review the Key Questions of Safe, Effective and Well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lavender Oaks Care Home on our website at www.cqc.org.uk.
Enforcement
We have identified a breach of the regulation in relation to safe care and treatment. This relates to management of risk around pressure ulcers. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.