21 Lucerne Road

What inspectors found

From the Care Quality Commission's assessment published 4 July 2024 (assessment visit 15 April 2024). Quoted under the Open Government Licence.

1. Safe

   GGood Good

   At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to good. At the last inspection we found breaches of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection sufficient improvements had been made and the provider was no longer in breach.

   Good progress had been made with the refurbishment of the environment. The front and back garden were upgraded and refreshed, providing people with a safe and pleasant area in which they were able to relax. Improvements to the inside of the property were well underway but were not fully complete at the time of this inspection.

   Following concerns raised prior to this inspection about staffing levels, the registered manager introduced a new staffing rota that is clear about the staffing of each shift and the duration of each shift. After this inspection the service had enough staff to meet people's needs and keep them safe.

   Staff understood the best ways to communicate with people. People could take part in activities they were interested in. Both the risk assessment and care planning processes had recently been revised and updated. Care plans were person-centred and current. People were protected from the risk of harm and abuse. People's medicines were managed so they received them safely.

   Staff received training in infection control and PPE. The premises were clean and hygienic. A relative told us, "It's clean here as you can see. I'm happy with the way they keep it." Staff had good levels of support, including training and supervision. Comments included, "We have good access to regular training and the training I have had is good”. The registered manager acknowledged the frequency of supervision meetings needed improving and showed us a new supervision matrix that set out six to eight weekly individual supervision for staff.

2. Effective

   GGood Good

   People’s needs and risks from harm were assessed together with input from their relatives and healthcare professionals. This was to minimise identified risks and help keep people safe. risk management strategies were developed in the care planning process to minimise these risks and to help keep people safe. Staff told us they found people’s care plans helpful in knowing how to support people appropriately especially when they were experiencing signs of anxiety or distress.

3. Caring

   GGood Good

   People were supported to have 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.

4. Responsive

   –No rating No rating

   At the last inspection we found people were at risk of not receiving the care and support they needed because sufficiently detailed care plans were not in place for them. This issue contributed to the breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Since that inspection the provider introduced a new format for care planning, integrating people’s needs and risk assessment into those plans. The registered manager told us regular annual reviews of people’s care plans were scheduled unless their needs changed first and this would trigger an earlier review. We saw evidence of these measures. This means there is good guidance in place for staff to follow about for people’s care and support and the provider is no longer in breach.

   People were in control of their care and support. Staff knew people well and supported them to follow their interests, including those related to their spiritual beliefs. There were systems in place to obtain regular feedback.

   People received care, treatment and support that promoted equality and protected their rights.

5. Well-led

   –No rating No rating

   At our last inspection we rated this key question requires improvement. This meant the service management and leadership was inconsistent. We found the provider failed to have effective oversight of the service and we issued a warning notice. The oversight of the registered manager to meet their regulatory responsibilities were lacking and needed to be improved. These issues contributed to the breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

   At this inspection the Registered Manager told us management issues identified at the last inspection were carefully considered and they were applying to the Care Quality Commission to deregister as Registered Manager. The Deputy Manager has applied to become the new Registered Manager. We saw evidence on our records of these application having been submitted. At this inspection we found the provider had made the necessary improvements. New monitoring and auditing processes were introduced to help ensure issues were identified and resolved such as with the premises and equipment, risk assessments and care plans. We found no evidence that people had been harmed and the provider had made some improvements. This meant the provider was no longer in breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

   We spoke with the managers about the improvements made since our last inspection and the actions they had completed to rectify the issues we previously found. Breaches of regulation had been addressed. Staffing levels had improved and quality assurance systems were now working more effectively. Concerns in relation to the safety of the environment were in the process of being rectified. This reflected the provider’s commitment to continual improvement and taking action when shortfalls were identified.