Lavender Villa

Updated 6 November 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was undertaken by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Lavender Villa is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At the time of the inspection the service did not have a manager registered with the Care Quality Commission. They had a manager who was registering for one regulated activity (Accommodation for Persons who require Nursing or Personal Care) and were in the process of recruiting a manager for the other regulated activity (Treatment of Disease, Disorder and Injury). The registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since it was last inspected. This included information from the service about events they are required to tell us about and information received from people who had shared their experience of care with us. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with 11 people who used the service about their experience of the care provided. We spoke with 13 members of staff including the area director, compliance officer, clinical lead, nurses, care workers, auxiliary workers and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We spoke with three relatives to gain their views on how their family members were supported at Lavender Villa either on the telephone or during our site visit. We observed how people were being supported during the day and walked around the service to ensure it was clean and a safe place for people to live.

We reviewed a range of records. This included five people’s care records and multiple medication records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records and other supporting information provided by the service. We attempted to contact other professionals, staff and families for additional feedback about the service.

Updated 6 November 2021

About the service

Lavender Villa provides nursing and personal care for up to 40 people who require functional mental health care. At the time of our inspection there were 35 people using the service.

Lavender villa is a purpose build single story building set within the Grosvenor Villas complex of care services. People have their own bedrooms and can access a variety of communal areas including living, dining and outside areas and adapted bathrooms.

People’s experience of using this service and what we found

Systems for checking the safety of care were not always robust and did not identify some of the shortfalls we found at this inspection. The management and staff team were keen to drive improvement within the home and people spoke positively about how they were supported to achieve good outcomes. The service was in the process of restructuring the management team and some recruitment in this area was ongoing.

People were happy with how they were supported with their medicines. However, records did not always contain enough detail about how staff should support people who required their medicines to be given covertly or had medicines prescribed that they needed occasionally. We made a recommendation that the provider review best practice guidance to ensure people are safely supported to take their medicines. Staff were safely recruited and generally there were enough staff to meet people’s needs. The service completed relevant risk assessments and staff knew how to reduce these risks as much as possible and relevant records were in place.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Care plans were in place, although the quality of records varied. People spoke positively about how they were supported, and staff had received a variety of relevant training and spoke positively about the induction process. People were supported to access health care services as needed. People enjoyed their meals and could choose what they wanted to eat.

Staff were kind and caring and knew people well. People’s privacy and dignity was respected. People were encouraged to remain independent where possible and supported to make decisions for themselves.

People and relatives were involved in developing care plans. People were supported to access a range of activities both within the service and in the community. People felt able to raise concerns, and where complaints had been made these were investigated. People’s end of life care needs were considered and staff were able to complete training in this area.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 30 April 2020) and there were a number of breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found some improvements had been made but the provider was still in breach of one regulation.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We have identified a continued breach in relation to the robustness of the systems of checks and audits at this inspection. We found no evidence during this inspection that people had come to harm from this concern and the provider took quick action to address any shortfalls we identified. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.