Lavender Lodge Nursing Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation to person centred care.  

This service scored 36 (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 received person centred care at all times.

The provider’s policies highlighted the importance of ensuring involvement from people within most aspects service provision, such as care planning. However, the provider failed to ensure these policies were followed as people and their relatives were not involved in care planning or feeding back into the running of the service. Therefore, we could not be assured people were at the heart of the service. Our observations supported this.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.



Staff had not received specific training relating to some of the care needs of people using the service. Therefore, we could not be assured staff fully understood the needs of the service group they were supporting. In addition, professionals told us some issues which could be dealt with by the nursing staff at the service were often passed onto them to manage.

However, one person told us about support they self-funded from an external organisation which they used prior to living at Lavender Lodge. This person was supported to continue to use this organisation and staff showed awareness of the support provided to this individual, sharing information appropriately.

The provider did not meet the information and communication support needs of people.



Some people living at the service were unable to speak and/or understand English. There was minimal support in place to ensure people who spoke other languages were understood. For example, for one person using the service, a picture card was used by staff to communicate in their language. However, this picture card contained only 10 phrases, most of which were directives and therefore meant the person had had limited opportunities manage their care and treatment. Failure to overcome barriers to communication placed people at risk of not having their care needs met and limited their opportunities to be involved in the service.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

The provider did not carry out questionnaires or surveys to seek feedback from people or relatives on their experience. There were no resident or relative meetings held for people to be involved in the running of the service.

People and relatives feedback confirmed this. One relative told us, “I’ve asked to speak with the manager but [they’re] always busy”, another said “I have sent emails to the manager, but they just bounced back. Communications need to be improved.” And “There is not enough communication between the home and relatives generally.” A person told us they were not asked for their feedback. They said they used to have a resident representative people could speak with and the representative would join staff meetings and feed back to the staff, but this no longer happened. Leaders told us that they had attempted to set up a resident meeting the year prior but had minimal attendance and were not sure what more they could do to encourage feedback.



A complaints policy was in place and included within the service user guide.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

Due to inconsistencies in record keeping, incomplete records and lack of checks of care records by management we could not be assured systems were in place to address any barriers to accessing care which people may have faced. This included making timely referrals to other agencies or identifying changes in need.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. As appropriate adjustments had not been made for individuals with communication support requirements, nor were there any systems in place to feedback for people using the service and as people were not involved in care planning the provider had not taken all reasonable steps to empower disadvantaged groups.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.



People and relatives were not always consulted with as part of end-of-life care planning. Care plans were not reviewed or updated promptly as people were considered to be reaching the end of their lives. End of life care plans had minimal person-centred details on how they wished to be cared for, including any religious considerations. For example, one person’s care plan simply said, ‘To ensure end of life wishes are respected and implemented,’ with no further details on what the person’s wishes were.



Additionally, staff had not received end of life care training. This meant staff had not been trained on signs and symptoms to monitor which may indicate a person was at the end of their life and how to care for them. This placed people at risk of dying without dignity.