21 Lucerne Road

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

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.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe. One person said, “I feel safe here. I get on really well with staff, they are like family to me. Staff help me out whenever I need it.” Another told us, “I feel very safe. They [staff] know what they are doing.” Feedback from family members was generally positive. Comments included, “I think [family member] is safe,” and “[Family member] is looked after safely, there have been no incidents. They are always two staff here whenever I visit.”

Staff were aware of the policies and procedures to follow and staff understood what to do to ensure people were protected from abuse. Staff said they had had appropriate training. One staff member commented, “I would inform the manager and document what happened.” Another told us, “If I saw any matters of concern, I would support the resident and report it to the manager and record it.” The registered manager was aware of their duty of candour and which agencies, incidents needed reporting to. Staff also knew the process for whistleblowing and how to report anything related to this.

The service had a registered manager in post at the time of our inspection. They were aware of their registration requirements with CQC and of their duty of candour. We noted people seemed very comfortable and happy living in the home and were evidently well settled having lived there for in excess of 20 years. We checked accident and incident records, these had been completed appropriately to date.

There were established policies and procedures in relation to safeguarding and whistleblowing in place and training records confirmed that staff had received regular and appropriate safeguarding training.

People and their relatives told us they were involved in drawing up their care plans and risk assessments. Relatives of people said their family members were supported in ways that helped reduce identified risks. They said some people experienced anxiety and distress at times. Relatives told us the staff’s day to day support and management of their family members anxiety and distress was appropriate and met their [family member’s] needs. Relatives said staff enabled people to access the local community appropriately with reduced risks for themselves and others.

People's individual risks were assessed and risk management strategies were developed to minimise these risks and keep people safe. A new risk assessment and care panning process had recently been introduced. 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. Comments included, “Care plans have recently been reviewed and contain relevant information that help us support people appropriately”, and “Support plans are useful because they are all about the person, their needs and wishes.”

We noted on the day of the inspection people were supported appropriately and risks to people were well managed. For example, one person wanted to go out with their relative shopping. This was enabled by staff and the relative of the person working with the identified risk management plan. The outing went well with no incidents.

General risk assessments were carried out. These helped to ensure the safety of the home environment and equipment for people, staff and visitors. These risk assessments covered health and safety, fire prevention fire systems, hot water safety and electrical appliances. Regular maintenance checks were undertaken for fire protection systems including the emergency lighting systems, fire extinguishers and the fire alarm. Risks to people from fire were reduced because staff and people knew what to do in the event of a fire. People had Personal Emergency Evacuation Plans (PEEPs) in place which guided staff on how to help people to safety in an emergency such as a fire.

People said they were very happy living at Lucerne Road and indicated they felt safe and they liked their bedrooms. They said it was their home and it was like their extended family. Their relatives told us they felt their family members were safe living in the home. They said they had never had any concerns about safety issues for their family members in the 25 years they had been living there.

The registered manager acknowledged improvements needed to be made with the condition of the environment both internally and externally. They said a refurbishment plan had already been drawn up and work progressed on making the necessary improvements. The builders told us about the work being carried out in the renovation plans as set up by the provider and the expectation was to get this completed within a few weeks.

On the days of the unannounced inspection, builders were on site working on the rear garden and buildings. Work had also been started on the internal repairs and upgrades as required.

A new auditing procedure was recently introduced to be carried out by the managers on a regular basis in areas such as with health and safety, the home environment, medicines management, care plans, staff records. The registered manager said part of the new system required action plans to be developed to address any issues or concerns identified. This would assist in preventing issues arising and not being addressed such as those identified with the environment.

People indicated they felt well supported by staff. Relatives told us they visited their family members regularly and often without notice. They said there were always 2 staff on every shift when they visited. One relative said, “There are always 2 staff on duty whenever I visit . There are enough staff on duty to meet people’s needs.” Another relative said,” I visit once a week and there are always 2 staff on duty whenever I go there. My [family member] is well cared for by kind and compassionate staff. He loves it there and doesn’t want to move anywhere else.”

Staff told us they received support through supervision. This included one to one meetings and team meetings. The registered manager acknowledged the frequency of these formal meetings did not meet the provider’s own policy to do with staff supervision. The registered manager assured us that this was understood. They showed us a new supervision matrix that set out regular six to eight weekly individual supervision for individual staff members. This was recently introduced together with a new supervision format. This set out the agenda for supervision meetings and included the direct work staff undertook with people. These measures when fully implemented should ensure staff have the skills, knowledge and experience to deliver effective care and support. We were happy from staff comments we received that they felt appropriately supported by managers with their work. We will monitor the progress of this work and will review it either at the next inspection or earlier if the need arises. Staff told us they received training in core areas such as first aid, infection control, the Mental Capacity Act, safeguarding, food hygiene and equality and diversity. Training programmes also included training on working with people whose behaviours resulted from anxiety and distress, epilepsy, autism and the administration of medicines.

On the days of this inspection there were 2 staff on duty for each shift to meet people’s needs. We inspected the training and supervision matrices. They reflected staff received regular and appropriate training and supervision.

The registered manager recognised recently there had been a lack of clarity with regards to the staffing rotas which had lead to concerns about the actual numbers of staff available. They told us additional staff had been recruited to ensure safe working hours for all staff were achieved. A new and revised rota was in place which reflected this. We were also told that there were appropriately recruited bank staff who could be brought in when or if people needed additional support and we saw evidence of this. Agency staff were not used by the provider. The provider’s recruitment practices were followed to help make sure that all staff were suitable for their roles in the home. The process included carrying out interviews, criminal records checks, proof of identity and taking up two references. This meant people were supported by staff whom the provider assessed to be safe to deliver care and support.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us people’s health needs were well met and as far as they were aware there had been no issues or problems with people receiving their medicines.

Staff told us they had received medicines training and their knowledge of the policies and procedures to do with the safe administration of medicines was assessed by the registered manager before they were able to administer medicines. We saw records that showed staff received medicines training and that there were regular audits of medicines to help to ensure the safe management of medicines. The registered manager told us they had recently introduced a new process to monitor staff competencies, in order to ensure quality standards were maintained.

People's medicines were managed so they received them safely. We found there were appropriate arrangements in place in relation to obtaining, storing, administering and the recording of medicines which helped to ensure they were given to people safely. All the medicines were safely stored away in a locked medicines cabinet. We undertook a medicines stock check to see if the stock of medicines held in the medicines cabinet was the same as that which was recorded on the medicine administration record (MAR) sheets. The check found one discrepancy with the levels of medicines held in the cabinet and the MAR sheets. Upon further investigation this was found to be recording error and people had received their correct medicine dosages. The registered manager told us they would improve medicines audit procedures in order to minimise any re-occurrences. People's records contained information about their prescribed medicines and how they should be supported with taking their prescribed medicines.