Lavender Lodge Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. Concerns about safety were not always reported or investigated.

Lessons were not learnt to continually identify and embed good practice. At the time of our inspection there were no systems in place to oversee accidents, incidents and falls. Not all reports of accidents and incidents were fully completed by staff or reviewed by leaders. There was no analysis into accidents and incidents to pick up on trends and therefore mitigate ongoing risk. This placed people at risk of further safety incidents. On day 2 of our inspection, leaders retrospectively reviewed and analysed the previous months’ accidents and incidents.



People and their relatives did not feel encouraged or able to raise safety concerns. One person told us, “I keep quiet.” Relatives told us communication around safety concerns needed to be better. One relative told us their loved one had an injury, but no explanation was offered about how it had occurred.

The provider did not always work effectively with people, and those important to them to establish and maintain safe continuity of care when moving between services. Risks were not well monitored.



People and their relatives were not always involved in care planning. This placed people at risk of receiving care that did not meet their person-centred needs. The pre-admission process did not always consider whether referrals to healthcare professionals were required. This included identifying whether additional equipment was needed, or support to improve independence.



People gave mixed feedback on their experience moving into the service. On person told us their admission was ‘upsetting’, explaining, “When I came in all I could see were people sitting in a circle in chairs not doing anything, it’s still like that.” A relative shared, “The communication with the manager hadn’t been great because I had to keep chasing and chasing for answers.” Another told us, they had filled in an assessment online but that had gone missing. However, one relative said, “They were fantastic, it went well.”

Staff felt the sharing of information about admissions, or changes in people’s needs was effective.

People were not always protected from the risk of abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Whilst referrals were made to the local authority where potential abuse was identified, leaders did not always record any internal investigations into allegations. Instead, they were led by instruction from the local authority into any actions required. This meant any immediate actions to improve safety, or opportunities for learning, where the local authority safeguarding threshold was not met, were missed. A safeguarding tracker showed 11 safeguarding referrals between July 2024 and February 2025 which had no outcome, or internal investigations recorded. Furthermore, as incidents were not always fully recorded or reviewed, we could not be sure concerns would always be effectively identified.

Not all staff had completed safeguarding training. Some staff told us safeguarding training was completed 3 monthly, others said annually, and some did not know when they had last completed this training. The provider told us all staff had been given a deadline to complete all outstanding mandatory training.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People and their relatives were not involved in their care planning, or assessment of risks. One relative told us, “I’m not aware of a care plan.” Another said, “I’ve not seen anything on the system.”

Risks to people were not always identified or robustly assessed. For example, associated risk assessments to support staff on how to safely manage seizures, including during bathing or out in the community were not in place for those with epilepsy. Furthermore, sufficient guidance within moving and handling risk assessments was not in place for people who required equipment and staff intervention when moving and handling. This included how to support people safely if moving and handling caused them distress. This placed people risk of harm.

Risk assessments were not reviewed following changes in people’s needs. For example, one person’s skin integrity risk assessment had not been reviewed after developing a pressure sore. This placed them at risk of receiving unsafe care. In addition, records did not always show people received the care they needed to maintain their skin integrity. For example, where people required support from staff to regularly reposition to provide pressure relief, records showed this was not always provided. We reviewed repositioning records for those with pressures sores and identified as high risk of pressure injury and identified significant gaps of up to 32 hours within repositioning records. This meant we could not be assured people had been repositioned and placed them at risk of pressure sores.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.



The environment was worn and tired. Records of health and safety checks had not been regularly completed. For example, hot water temperature checks. External checks on health and safety within the service had been carried out, however the actions identified for improvement had not been completed. This included actions to improve fire safety. This placed people at risk of living in an unsafe environment.

The service was split into 2 areas named the traditional side and the new side. There was no signage to help people navigate. People’s bedrooms were not clearly identifiable with names or numbers to help people with cognitive impairments orientate.

People and relatives felt the environment required improvements to make it comfortable and homely. One relative said, “His room is quite cold, and the blind is wonky. The room looks quite uncared for.”



However, we observed people had access to the specialist equipment they needed to keep safe. This included moving and handling equipment. The provider assured us a refurbishment plan was in place to improve the environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.



Not all staff had completed mandatory training. This placed people at risk of receiving unsafe care. The provider had set a deadline for all staff to complete their mandatory training.

The provider did not have an effective approach to determine the number of staff to meet the needs of people using the service and always keep them safe. Staffing levels were last reviewed on 17 December 2024, despite changes in numbers of people using the service, and changes in need. This meant we could not be assured staffing levels were appropriate for the needs of people using the service.

We received mixed feedback on staffing levels at the service. When asked about call bell responsiveness, one person told us “I hardly use them, but they aren’t answered quickly. If I want to go back to my room, I have to sit and wait. There’s nothing I can do about it.” Another person said, “Need more staff and better training.” However other relatives said, “I think there is enough staff. The staff do come in from time to time to check on [person]. There are always staff about.”

Staff also provided mixed feedback. Some felt additional staff were required, others felt staffing levels felt manageable. Some staff told us they had not had a supervision, others said they met regularly with management. Staff confirmed they had an induction, and we received some feedback that this needed to be more in depth, particularly for those with no care experience.

During our site visit, we observed staff to supervise communal areas at all times. Staff did not appear rushed and attended to people’s requests for support promptly. We observed a moving and handling manoeuvre carried out safely by 2 staff.



Safe recruitment checks were carried out on staff prior to employment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.



As fixtures and fittings within the environment were not all well maintained and in a good state of repair, this made it harder for those areas to be cleaned to a high standard. The service was working through an action plan to ensure these areas were addressed.

However, generally the premises were observed to be clean. People were observed to be clean and well kept.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Where people were prescribed medicines to manage behaviour on an ‘as required basis’, documentation to support the safe and appropriate administration of these medicines was not in place. For example, there were no protocols to guide staff on signs and symptoms that meant a person needed the medicine, or non-pharmacological techniques to support someone in distress to try first. Additionally, there were no records to demonstrate why someone was administered medicine to manage behaviour, or any follow up on whether it was effective. Whilst we found no evidence people had been harmed, people were at risk of receiving these medicines inappropriately.

Medicine audits had identified areas for improvement, however at the time of our inspection action had not been taken to address these areas. Therefore, we could not be assured there was robust oversight of medicine management at the service.



People and relatives raised no issues with how they received their medicines. One relative told us, “[Person] had been helped to have medication regularly which improved their mental health and well-being.” We observed staff administering medicine during our inspection taking time to talk through with people what medicines were being given and what they were needed for.