21 Lucerne Road

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

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.

This service scored 54 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Relatives of people told us they thought the service was well managed. Comments included, “Overall we are very happy with the service. We have no complaints or concerns. Activities such as the annual holidays and trips are good and staff always ask [family member] what he would like to do. They provide good choices for him and he would not want to move”, “We are very happy with the service, he [family member] is very well looked after. We have no complaints at all. The activities are so good, they take them on holidays abroad and they did a trip to London recently, all of which he really enjoys. They are well looked after”, “They are well looked after and well settled there.”

There was a new and revised programme of audit and checks in place in order to identify areas for improvement. Action plans were put in place to provide a framework and timescales for improvements to be made. This included listening to feedback from people and their families and creating an action plan based on survey feedback.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.