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21 Lucerne Road Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 17 April 2020

About the service

21 Lucerne Road is a family run residential care home providing accommodation and personal care. It is registered to support up to three people with learning disabilities and/or autism. At the time of the inspection there were three people using the service.

The service has not always been fully been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service should receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service

At this inspection we found a continued absence of monitoring systems to improve the quality and safety of the service. This meant that some areas of risk had not been identified. The provider acted to address some areas we identified following the inspection, but they had not recognised these issues through their own quality monitoring. Some areas we had identified for improvement at the last inspection, such as systems for monitoring staff training had not been fully addressed.

The provider had addressed the issues we had previously identified in relation to DoLS. However, we found continued concerns about arrangements to ensure staff followed the Mental Capacity Act 2005 (MCA) code of practice.

Medicines were safely administered but arrangements for ‘as required’ medicines did not follow best practice guidance. Staff had not been assessed as competent to administer medicines.

We have made two recommendations, one about the use of best practice guidance on managing medicines and the other that the provider consults best practice guidance on positive behaviour support to better inform the planning of people’s care.

The registered manager was involved in the day to day care of people at the service and they were supported by a deputy manager. However, they had limited understanding of their roles and responsibilities. They had limited contact with other providers or health and social care professionals to help stay up to date with changes and developments in adult social care.

Some Improvements had been made since the last inspection and people were accessing the community for some activities. People had care plans that reflected their care needs. However, further improvements were needed to care records to evidence that outcomes for people consistently demonstrated the principles of choice and control, independence and inclusion. People did not always have information about the service in a format they understood.

People were not able to express their views to us verbally at the inspection. Relatives told us people were safe at the service and we observed people were relaxed in the presence of staff and each other. Staff understood how to protect people from abuse or neglect and how to raise safeguarding alerts if needed.

Details of accidents or incidents which occurred at the home were recorded. The registered manager and deputy reviewed accident and incidents for learning, to reduce the risk of repeated occurrence.

There were enough staff to meet people’s needs. Staff understood how to protect people from the risk of infection.

People’s nutritional needs were met. Staff received training and support, but improvements were needed to ensure the training was reflective of people’s needs. People had access to health care services.

Relatives told us staff were kind and caring. Staff knew people well and understood their likes and dislikes as well as their needs. Staff treated people with dignity and respected their privacy.

People were involved in making decisions about the support they received. Since the las

Inspection areas


Requires improvement

Updated 17 April 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 17 April 2020

The service was not always effective.

Details are in our effective findings below.



Updated 17 April 2020

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 17 April 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 17 April 2020

The service was not always well-led.

Details are in our well-led findings below.