Lucerne House

Lucerne House is a residential care home providing personal and nursing care to 72 people at the time of the inspection. They provide care to younger and older adults. The service can support up to 75 people. The building has three units. During the inspection Shillingford (also known as Memory Lane) provided care to 30 people living with dementia, Ide provided predominately nursing care to 28 people and Alphinbrook care to 14 younger adults.

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

People received an outstanding, personalised, caring service. People told us they received very kind and respectful support from staff who promoted their abilities, knew them well and genuinely enjoyed their company. The whole staff group worked as a team to support people in a person-centred way. Care was planned, risk assessed and put in place with full consultation and involvement of people and their relatives where this was appropriate.

People were valued and placed at the heart of the service. Staff promoted people's privacy and dignity and enabled them to make choices and have as much control and independence as possible which helped build meaningful relationships.

Feedback about the service from people, family and linked professionals always mentioned the service in outstanding terms. People said, “The staff here have time for you. They are always relaxed and happy and have time to chat and even banter with you” and, “I can’t fault the care here. I know the care I get here, courtesy of the wonderful staff, is of the highest order.”

Relatives commented, “I feel the care my relative receives is individually suited to their needs, and they are very much treated as an individual”; “The staff keep me very well informed about my relative’s condition and what’s happening to improve things since they moved here from hospital” and, “I visit my relative daily and without fail, the atmosphere is lovely and all the staff are so friendly and welcoming”.

People received effective care and treatment from competent, knowledgeable and skilled staff who had the relevant qualifications to meet people’s needs. The provider had a good system to ensure all staff had regular training to keep them up to date with best practice. Training courses and events were relevant to the people living at the service and staff ensured they put learning into practice.

People were assured of their rights being upheld to the maximum level possible. The service applied the Mental Capacity Act 2005 (MCA) to the full. People were supported to have exceptional choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the training, management, policies and systems in the service supported this practice. Every person bar none were seen as individuals and the staff sought to identify goals and aspirations for each person, so they could live their life to the greatest extent of their ability while at Lucerne House. Every effort was then made to ensure those goals and aspirations could be realised.

The service was accredited for its care of people living with dementia. Staff were trained to understand dementia and were passionate in ensuring they continued to put this into practice. Each person’s individual life and dementia journey was important to staff and was used to inform best interests decisions. The service established relationships with and worked with local groups, including schools and tradespeople, to improve the experience and understanding of people living with dementia. As a result of this carers were also supported.

Activities were provided seven days a week by a passionate and experienced activity team. These offered a wide variety of relevant and meaningful activity both inside and outside of the service. Staff got to know people and ensured activities were enjoyed and meaningful, using past interests.

Medicines were generally managed safely. There were clear processes and systems to ensure they were ordered, stored, disposed of and administered safely. The service worked closely with a local GP to ensure people’s medicines were reviewed often to prevent over medication. The mood and pain of people was monitored closely to ensure they were well. This meant people living with dementia with behaviour that may challenge were assessed closely, and other approaches were used, like distraction or meeting pain needs, rather than using medicines to suppress these behaviours.

People had access to plenty of food and drinks throughout the day and there were individualised meals according to their tastes and needs. People told us the food was very good and there was plenty of choice. Meals were appetising and served in a calm and organised manner, creating a sociable and pleasant meal experience.

The service was very well-led. The registered manager, management team and staff were extremely open to hearing feedback on the service and acting to correct anything the inspection team identified, immediately. There was an open, caring culture that was passionate about maintaining their Outstanding rating. Everyone told us, that this culture emanated from the registered manager.

The provider's quality assurance processes were effective and there was a focus on continuous improvement and continuously seeking out ways to offer personalised care. People, relatives and staff all felt valued as individuals and partners in their care and the running of the service. The registered manager provided empowering and very good support for staff to be able to do their job effectively. They, the staff team and the provider, acted to ensure continuous excellent quality care for people living at Lucerne House.

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

Rating at last inspection (and update)

The last rating for this service was Outstanding (The report was published 8 February 2017). On this inspection we found this rating had been maintained.

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

There was a registered manager and deputy manager employed at the home who were clearly passionate about providing a high quality, individualised service. The registered manager was on an additional temporary assignment within the company, so the deputy manager who commenced employment at the home in July 2015 temporarily manages the home when the registered manager is absent. The registered manager was present at Lucerne for the majority of the time.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection in October 2014 we found the domain of ‘responsive’ required improvement. At the time, people’s feedback was mixed about how they were supported to interact, avoid social isolation and pursue their individual interests and hobbies, and further improvement was needed in this area at that time. All of the management team had changed during 2014 and the two heads of unit were then relatively new in post. During this inspection in November 2016 we found there had been extensive improvement and we rated responsive as ‘outstanding’. People had access to and were involved in developing personalised activities that complemented their individual hobbies and interests. Links with the local community had been established and people were supported to participate in community events and other events that were important and meaningful to them. Some people were able to improve their independence so they were able to return home to the community. This provided people with a sense of purpose and wellbeing.

People were supported by very kind, caring and compassionate staff who often went the extra mile to provide people with good, high quality care. This high standard of care enhanced people's quality of life and wellbeing. The staff as a whole, supported by the activities team, were extremely passionate about providing people with support that was based on their individual needs, goals and aspirations. They were pro-active in ensuring care was based on people's preferences and interests, seeking out activities in the wider community and helping people live a fulfilled life, individually and in groups.

The staff were happy working in the home and felt very supported in their role. They were clear about their individual roles and responsibilities and felt valued by the registered manager, deputy manager and the wider provider, senior management team. Good leadership was demonstrated at all levels with a pro-active effort to encourage ideas from staff to further benefit the people in their care and maintain a strong, stable staff team with a shared goal. Each individual staff member was engaged in sourcing new opportunities for people and putting ideas into practice.

People were safe living at Lucerne House. There were enough staff to meet people's care needs safely and also to provide individualised support in and out of the service. There was a strong culture within the home of treating people with respect. The staff and managers were always visible and listened to people and their relatives/friends, offered them choice and made them feel that they mattered. Staff spent time with people to get to know them and their needs and this had ensured that behaviours that could be challenging for staff and distressing for people were minimised. People and the staff knew each other well and these relationships were valued.

Staff had received appropriate training in line with nationally recognised qualifications and regular supervision to provide them with the necessary skills and knowledge to provide people with effective care. It was not unusual for some people to gain independence during their time at the service to enable them to return to live in the community with support. People received their medicines when they needed them.

People received a nutritious diet and enough to eat and drink to meet their individual needs and timely action was taken by the staff when they were concerned about people's health.

There were very effective systems in place to monitor the quality and safety of the care provided. People felt able to raise any concerns and be confident they would be addressed. Where concerns were raised by people, relatives or through regular auditing we saw the home took them seriously and took appropriate actions to focus on learning and improvement for the benefit of the people using the service.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Lucerne House is comprised of three units known as Shillingford unit, which provides care for people with dementia; Ide unit, which provides care for older people, and Alphinbrook unit, which provides care for younger people with physical disabilities.

At our previous inspection on 24, 26 February and 03 March 2014 we identified significant concerns about the care and welfare of people, staffing levels and quality monitoring at Lucerne House. CQC took enforcement action by serving three warning notices on the provider, which required them to make urgent improvements in these areas within four weeks. We also identified concerns about five other standards, which were less serious.

This was a follow up inspection to check the most urgent improvements required had been made. We visited the home on 21 May 2014 and found the provider had complied with the warning notices served and had and made significant improvements in people's care and welfare, staffing and in quality monitoring. We have since received an action plan from the provider about the remaining improvements underway at Lucerne House in relation to the other five areas of non-compliance. We will carry out a further inspection later this year to check further improvements have been made and to ensure existing improvements have been sustained.

At the time of our inspection there were 59 people living at Lucerne House nursing home. Following the previous inspection, the provider agreed not to admit people to the home until improvements in care had been made. We spoke with 23 people who lived there and with seven relatives to seek feedback about the care. We spoke with 24 staff who worked at the home which included the manager and other senior staff, nurses and care workers, agency and other support staff. We also spoke with five health care professionals who regularly visited the home to seek their feedback.

Is the service safe?

As a result of the concerns identified at the previous inspection, a multiagency safeguarding process was convened to oversee the improvements. A multi-disciplinary plan was drawn up by the provider and health and social care professionals to protect people's safety and well-being. This resulted in health professionals visiting the home as part of a safeguarding investigation and in a protection role. Feedback we received from health and social care professionals confirmed our findings that care had improved across all areas of the home and risks had significantly reduced.

One person said, 'I like it here and I feel 100% safe'. We found that people were well supported to have adequate nutrition and hydration and we found the health of people previously at risk of malnutrition and dehydration had improved and they had gained weight. Security in the home had also been improved to prevent visitors having unauthorised access to the home. Health and safety systems had been improved, all damaged crash mats and bed bumpers had been replaced and were being closely monitored. People on Shillingford unit who needed hoisting had individual hoist slings, which had increased their safety and reduced cross infection risks.

Is the service effective?

Since we last visited, staff on Ide unit had undertaken training on nutrition, hydration and on end of life care. Staff we spoke with demonstrated much more knowledge and confidence in caring for people's needs. Nutritional care plans had been reviewed and updated to give staff much more information about how to support people's nutrition and hydration needs. Health professionals also reported they received fewer phone calls for advice between their visits due to increased staff confidence in providing care. People and relatives also reported improvements. One said, 'Absolutely fantastic, they are more organised' and another said, 'I can see huge improvements'.

Is the service caring?

Throughout our visit, we saw that people were treated in a caring and compassionate manner and with dignity and respect. We saw that staff were engaged with in meaningful conversations with people and treated people as individuals. Comments included, 'Mum is very well cared for' and 'Overall my family and I are very happy with the care our mother receives'.

Is the service responsive?

Staffing levels at Lucerne House had significantly increased. A number of staff we spoke with told us how the increased staffing levels had improved people's care. One said, 'Staff are not so stressed, we can sit with people at lunch and engage with them'. One relative said, 'X seems much calmer, staff can now spend more time with him, he is getting more to eat and drink regularly and I am pleased with that'.

We found that people were being regularly supported with personal care and that people who needed support to eat and drink regularly received that support. We also saw how care records had improved and provided better information for staff about how to respond to people's individual needs. Staff were responsive when people called out and quickly went and reassured them and they also responded quickly to call bells. We observed that staff sat down next to people who needed support with their drinks and discreetly assisted them, where necessary. We saw that staff were patient and allowed people time to eat in a calm unrushed environment.

Is the service well led?

People and relatives we spoke with reported improvements in the leadership and management at the home. The manager has been in post for three months and is currently undergoing registration with the Care Quality Commission to become the registered manager at Lucerne House. One relative said, 'The home feels more stable, the manager seems to be here more often, his door is always open which makes me feel happy to approach him if I felt I needed to'. Another relative said, I feel things are much better, we feel more confident in the home'.

We found the quality monitoring systems at the home had been improved and that prompt actions had been taken to reduce the risks we highlighted previously and to improve people's health, welfare and safety.

At our previous inspection in August 2013, we identified five areas of non-compliance with the Care Quality Commission's Essential Standards of Quality and Safety. These were related to people's care and welfare, equipment, premises, staffing and managing complaints. The provider sent us an action plan outlining improvements being made to become compliant. This inspection was undertaken to check the required improvements had been made.

We visited the home over three days and spent a day on each unit. We spoke with 27 people and relatives to gain their feedback about the service. We also received feedback directly from five relatives via our website. We looked at 14 people's care records. We spoke with 31 staff who worked at the home which included the registered manager, other senior staff, nurses and care workers, kitchen, housekeeping and maintenance staff.

Some people and relatives we spoke with were happy with the care and support they received. One person said, 'When I want them, they are there.' A relative said, 'The care is excellent, they look after her really well'. However, a number of people and relatives raised concerns with us about shortages of staff and about the lack of skills and experience of some staff. One person said, 'The main issue here is not enough staff, they are understaffed quite a lot of the time'. A relative said, 'Staff are mostly friendly and hard -working but some appear very inexperienced'. A second relative said, 'They are going through a difficult time of being short staffed, particularly in the evening'. A third relative we spoke with was really concerned the person wasn't getting enough to eat and drink.

Most of the staff we spoke with told us the home was short staffed on a regular basis. The registered manager confirmed they had reviewed staffing levels in relation to people's needs since the last inspection and had increased staffing levels. However, we saw that frequently, the recommended staffing levels required to meet people's needs were not being maintained due to staff absence. This meant people did not always receive the support and help they needed to maintain their health, safety and welfare.

We spoke with nine health care professionals who regularly visited the home to seek their feedback. Health professionals told us that the home contacted them appropriately for advice and support about people's care. However, several health professionals we spoke with raised concerns with us about the lack of knowledge and experience of some staff who worked at the home and about low staffing levels. One health professional said, 'It depends on which staff are on duty, some are very experienced, others less so', another health professional said, 'Some staff are struggling'.

During our inspection, we found staffing levels were not sufficient to meet people's needs. On Ide unit, we found staff were not able to meet some people's basic care needs in a timely manner such as providing support for people who needed assistance with eating and drinking. People on Ide unit were not adequately supported to have regular meals, drinks and snacks. Also, eight care records we looked at about people's eating and drinking were so poorly documented that we could not tell whether those people were given enough to eat and drink. We found nutrition care plans in relation had not been followed and three people had lost weight. This meant the care needs of people who were at risk of malnutrition and dehydration were not being met, which put their health, welfare and safety at risk.

We immediately raised our concerns with the provider about the lack of support for people with eating and drinking on Ide unit and gave clear feedback about the areas for improvement. The examples of poor management of care and poor practice we found on Ide unit were promptly shared under a safeguarding process. A multi-disciplinary plan was drawn up by health and social care professionals to protect people's safety and well-being. This resulted in health professionals visiting the home as part of a safeguarding investigation and in a protection role.

We followed up equipment concerns raised at our previous inspection about damaged and soiled bed rail bumpers and crash mat equipment. We found a number of people's bed rails bumpers and crash mats were soiled and torn. These were unsightly and undignified for those people and represented an infection control risk. We also identified ongoing security risks related to the main entrance of the home. This was because the reception desk was often unmanned during the day and because the main entrance was left open early in morning and between five and eight o' clock at night. This meant visitors and others had unrestricted access to the home, which put vulnerable people at risk.

The home had a number of quality monitoring systems in place, but some of these were not effective. This was because they were not identifying the risks we highlighted during the inspection such as about adequate nutrition and hydration for people, concerns about low staffing levels, soiled and damaged equipment and t security risks. This meant prompt actions were not being taken to reduce those risks which put the health, welfare and safety of service users and others at increased risk.

We found the home had not made the required improvements and was not compliant with any of the eight standards we inspected.

We spoke with 16 people who used the service, along with 13 visitors/relatives to gain their views of the service provided. We also received information from two relatives following the inspection who raised concerns about the standard of care provided and staffing levels. We spoke with 23 members of staff including the senior management team, nursing staff, care staff, ancillary staff and agency staff.

People we met during our inspection told us that they were generally satisfied with the service they were provided with. They often spoke highly of the dedication of the staff team. Comments included, 'The staff are nice to me', 'All of the staff treat us with respect and consideration', 'Staff are lovely. They couldn't do more for me'. When asked if there were any improvements which could be made, six people told us they would like to see more staff available. Comments included, 'The biggest problem is the lack of staff. This means I have to wait for attention'; 'There are not always enough staff. Sometimes I can't find staff to help me'; 'I can wait for 30 minutes or more for help. The staff are always busy' and 'I wish there were more staff. That's my only negative comment'.

Not all the people we met were able to verbally tell us about the care they received and their experience of living in the home. Therefore we observed how staff interacted and supported people, to enable us to make a judgement on how their needs were being met.

Some relatives told us they were happy with the overall care provided. One relative told us, 'The staff understand X, his character and humour'. Another relative told us, 'We are happy with the care although they do appear to be short staffed at times'. Other comments included; 'Mum is looked after well. She gets on with the staff. They make her laugh'; 'We are appreciative of care. There are incredible individuals within the staff team who go that extra mile'; 'There are lots of lovely staff, however, I am not sure there are enough of them. Some people here are very ill and need a lot of attention'.

We spoke with a range of health and social care professionals including two GPs; a speech and language therapist (SALT); a care manager; continuing care nurse and a tissue viability nurse. Professionals were positive about the care provided on Shillingford and Alphinbrook saying that staff acted on and responded to their recommendations. However, concerns were raised with us about the staffing levels on Ide Unit and how this impacted on the level of care provided to some people.

During this inspection we identified five areas which required improvement. People did not always experience care, treatment and support that met their needs and protected their rights. This service provided care and support to a high number of people with complex needs and high dependency, including people with palliative care needs. We found that this was not reflected in the numbers of staff available to provide care. People were not always protected from unsafe or unsuitable equipment. There was a complaints system available, however information provided to people about the system was not accurate. Comments and complaints people made were not always responded to appropriately.