Lavender Lodge Nursing Home

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.

This service scored 38 (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, well-being and communication needs with them. Relatives confirmed they were generally told if there were any concerns regarding their loved one’s health and well-being, however, they were not involved in the care planning process. 



Nationally recognised assessment tools were used; however, it was not always clear how these were used to inform people’s care. For example, a widely used risk assessment tool to assess skin integrity was used, however where it identified high risk of pressure ulcers, care records did not consistently record and implement timely, targeted interventions to prevent them. Additionally, the tool was not reviewed as people’s needs changed. This placed people at risk of receiving care which did not meet their needs.

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 weights were monitored; however, improvements were required to ensure referrals and recommendations from healthcare professionals were consistently recorded as it was not always clear if weight loss was being promptly addressed. Additionally, fluid charts were not always fully completed to show people had been supported to maintain their hydration.



Kitchen staff understood people’s dietary requirements, including how to prepare modified meals for people with swallowing difficulties. The menu was under review, however people fed back positively on the food at the service. The mealtime experience was calm, and people received support to eat their meals as required.

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

People and relatives fed back on staff changes and the impact this had when information was not effectively shared. One person told us, “There are that many different staff who don’t know anything, so it takes them twice as long.”

We received feedback from healthcare professionals that communication between night staff and day staff was not always effective when flagging concerns for GP review.

Staff used the electronic care planning system to flag any updates for regular handover meetings held twice a day where staff shared important information to the next shift. Staff reported this worked well.

The provider did not always support people to manage their health and well-being, so people could not always maximise their independence, choice and control.

Records did not always show how people were being supported to improve their health and well-being as any recommendations from healthcare professionals were not always reflected within people’s care plans and risk assessments. For example, one person had been assessed as end of life by a healthcare professional, but their end-of-life care plan had not been updated to reflect this significant change.



People were not always supported to reduce their future needs for care and support. One person told us they had missed a recent hospital appointment and were awaiting a new one. A relative told us, “[Person] went from walking, to walking with a stick, to walking with a walker, to not walking.”



People were supported by a regular GP ward round. A range of healthcare professionals were observed to visit and support people during our site visits.

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.



We found examples in records which showed care was not being robustly monitored. For example, skin integrity checks carried out by staff were not fully completed and missing key information to allow a robust clinical assessment. This placed people at risk of further skin deterioration.



Additionally, professionals felt improvements were required in the monitoring of baseline observations for people who were identified as deteriorating in health. This meant healthcare professionals were not able to compare people’s presentation with what was considered normal for them.

We received feedback that prompt action to improve people’s health and well-being was not always taken. One relative told us, “They told me about [an injury] and then five days later they said that they had taken [person] for an x-ray. I thought it strange that they would wait five days before checking that out. [Person’s] wrist is still bruised now.”

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. The provider did not always follow the principles of the mental capacity act (MCA).



General mental capacity assessments were in place, for example in relation to consenting to live at the service and consent to receive care and support. However, we found these were not in place for all required decisions. For example, 2 people using the service shared a room. Whilst both people told us they were happy to share a bedroom, staff told us 1 person did not have capacity to consent to this decision. There were no records of any mental capacity assessment, or best interest decision in relation to sharing a room. Following our site visit a mental capacity assessment was carried out.



Staff had not received MCA training. One staff told us, “I have not had MCA training at Lavender. I don’t think the other carers have received this training.”

However, we observed staff support people to make day to day choices. For example, what they wanted for lunch.