Lavender Lodge Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.



The culture of the service was poor. The provider did not have effective processes in place to demonstrate it listened to and acted upon concerns, were open and responsive to suggestions, and used systems to drive improvement; all of which helped to ensure an open and transparent culture was in place.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.



The service was not well-led. Policies to ensure good governance had not been followed. For example, no audits had been completed for care plans. This meant areas of risk, or improvement had not been identified or actioned.



This was reflected in feedback received. One relative told us, “The manager needs more of a presence, they are not approachable at all.” Another said, “I don’t see much of the manager, they are not out and about.” And “The manager doesn’t speak to anyone.” Other people were not aware of who the manager was. A notice was attached to the management office stating, ‘urgent meeting do not disturb’. We had received feedback this had been attached to the door for some time. This did not encourage people or staff to approach the management office to share any feedback.

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

People did not feel able to speak up and feel that their voice would be heard.



We were concerned about some people’s response to our inspection and request for feedback. We found people were not always forthcoming and concerned about being heard by staff or management. One person said, “I won’t get into trouble, will I?” Another said, “You don’t want to rock the boat.” And “It used to be dreadful, keep your mouth shut or you go to the back of the line.” This did not demonstrate leaders had encouraged a positive and open culture where people could raise concerns without fear of detriment.

Staff raised no concerns about discrimination at work. However, due to lack of channels to feedback we could not be assured staff were provided with opportunities to raise concerns.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The governance systems in place had failed to ensure a consistently good service was delivered and had not identified the widespread shortfalls identified at this assessment.  



Following our assessment, the management consultant provided assurance that an in-depth overhaul of the governance systems would be implemented as part of their support.

Overall, the provider worked in partnership with relevant agencies. Areas of concern had been identified through stakeholders, and leaders were working collaboratively to address the issues found. We received positive feedback from professionals, including, “Working with Lavender Lodge overall is good, I feel we have good relations.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider failed to ensure effective action was taken where areas for improvement or risk were identified. This placed people at risk of harm.

An action plan was in place at the time of our assessment; however, this had been created in response to findings from partner agencies and had not been generated from the providers own internal governance systems.

Following our assessment, an updated service improvement was provided which prioritised actions with clear timescales and ownership.