Lavender Lodge Nursing Home

Updated 7 February 2025

Date of Assessment: 18 February to 26 February 2025. The service is a nursing home providing support to older people living with dementia and/or physical disabilities.



An effective system to report, review and analyse safety incidents was not in place. People’s identified risks were not robustly assessed and mitigated, and people’s care records did not always demonstrate they had received the care they needed. Staffing levels were not informed by an assessment of the needs of people using the service. Records to support the safe administration of medicine used on an ‘as required’ basis to manage behaviour were not in place. People’s person-centred needs were not always met. Communication support was minimal for people whose first language was not English. End of life care planning lacked person-centred details on how people wished to be cared for. Governance systems were not in place to oversee key risk areas, such as care planning and provision. Where audits were completed, these did not always identify risk or drive improvement. Policies were in place, but not always followed.



Some areas within the environment needed refurbishment, but overall, the premises were clean. Some staff training was out of date, which management were addressing.



Following our assessment, the provider immediately instructed a management consultant to provide intensive support and oversight at the service.

The provider was in breach of the legal regulations relating to person-centred care, safe care and treatment, and good governance.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.

Updated 7 February 2025

People did not feel able to raise concerns about safety. We found people did not feel encouraged to speak up as a positive and open culture was not promoted. There were no systems in place for people to feedback. People told us they were not involved in care planning. Most people and relatives we spoke with had not seen a care plan. Some people felt more staff were needed, and staff did not attend to their requests for support quickly. Other feedback was that there were enough staff.

People and relatives felt improvements were required to support people to maintain their health, well-being and independence. A relative told us, “They don’t support people to stay independent.”



People didn’t have enough to do. One relative told us, “There is zero going on.” Another said, “There is no activity programme…[Person] has nothing to do.” Some people who were independently able could access the community, but due to staff availability, those who needed support were not able to go out as often as they liked.

Some people felt staff rushed people and did not always understand their needs. Others felt staff maintained their dignity when supporting them.



Some people using the service were unable to communicate verbally with us. We therefore carried out a short observational framework for inspectors (SOFI) to observe people’s experience of care. This showed us that staff did not always interact with people other than when carrying out tasks. People were given choices in their day-to-day care.